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OPERATIVE DENTISTRY. 



LINDSAY & BLAKISTOFS DENTAL PUBLICATIONS. 

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HARRIS'S DICTIONARY OF MEDICAL TERMINOLOGY, DENTAL 

SURGERY, AND THE COLLATERAL SCIENCES. 

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4. 
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Founded on the Anatomy of the Parts involved in the Operation, &c, &c. 
Second Edition. 12mo. $1 50. 

5. 
TAFT'S PRACTICAL TREATISE ON OPERATIVE DENTISTRY. 
A new "edition, thoroughly revised, containing 86 Illustrations. 
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6. 
FOX AND HARRIS ON THE HUMAN TEETH. ' 
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With 208 beautifully executed Illustrations. Octavo. Sheep, $4 50. 






PRACTICAL TREATISE 



OPERATIVE DENTISTRY, 



By JR TAFT, 



PROFESSOR OF OPERATIVE DENTISTRY AND DENTAL HYGIENE IN THE OHIO 
COLLEGE OF DENTAL SUROERY. 



$ttw& ®flitu>», 



WITH 



EIGHTY-SIX ILLUSTRATIONS. 




PHILADELPHIA: 

LINDSAY & BLAKISTON 

1868. 



^ 






Entered, according to Act of Congress, in the year 1868, 

BY LINDSAY & BLAKISTON, 

In the Clerk's Office of the District Court for the Eastern District of 
Pennsylvania. 



HENRY B. ASHMEAD, PRINTER, 

Xos. 1102 and 1104 Sansom Street, Philadelphia. 



PREFACE. 

SECOND EDITION. 



The preparation of the present edition of this work, 
has been attended with more labor and effort, than 
the author had anticipated. 

The first edition at the time of its writing was de- 
signed to embody and present the principles and prac- 
tice of the profession in the operative department, in 
its highest attainment. 

Since that time, however, so great have been the 
changes in many points of practice and application of 
principles, that those given as the best, nine years 
ago, are superseded by others and out of use ; so that 
in many particulars the labor has been almost equal 
to the preparation of new matter. 

The object in this, as in the former edition, has been 
to bring the work up to the present status of the pro- 
fession ; and though it has been accomplished with 
many misgivings and consciousness of defects, the 
author is not without hope that it may be of value to 
those preparing to enter the profession, if not to those 
already in it. 

Cincinnati, April 1, 1868. 



PREFACE 



The exigences of the Profession seemed to require, 
for the department of Operative Dentistry, a work 
that should contain all that is known in this branch 
of the science. To answer that requirement, the 
author of the present work has aimed to furnish, in 
as compact a form as possible, the Principles of the 
Science, properly digested, the Experiments Detailed, 
the Manipulations Described, and the whole method- 
ized and thus made available to the Student and the 
Practitioner. In the accomplishment of this object, 
he has, he believes, included everything meritorious 
or important in this department of Dental Study. 

To the dental writers whose labors have lightened, 
in any degree, the toil of this undertaking, the intelli- 
gent reader y T ,ill ascribe the credit due ; and to the 
members of the profession, whose suggestions have 
found place in various parts of the volume, the author 
gratefully acknowledges his obligations. 

J. TAFT. 

Cincinnati, July 1, 1859. 



CONTENTS 



~~. 




CHAPTER I. 






PAffE 


Introduction, . - 


17 


Deposits, ...... 


18 


Tartar, 


18 


Origin of, 


19 


Points of Deposit. 


.20 


Effects of, . 


21 


Method of Removing, . 


22 


Green Tartar, ..... 


24 


Origin of, ... . 


25 


Treatment of, ... 


26 


Irregularity, ..... 


27 


Effects of, . . . . 


28 


Atrophy, . , . . 


29 


Cause of, ..... 


30 


Effects of, ..... 


. 32 


Exostosis, . . . . . . 


31 


Effects of, ..... 


34 


Cause of, ..... 


34 


Denuding, ..... 


35 


Chemical Abrasion, ..... 




Cause of, . 


38 


Necrosis of the Teeth, .... 


39 


Causes of, 


41 



Xll CONTENTS. 



CHAPTER II. 



Caries of the Teeth, ...... 42 

Causes of Caries, . . . . . .52 

Predisposing causes of Caries, ... 52 

Exciting causes of Caries, . . . .56 

Comparative liability to Decay, ... 63 

Consequences of Caries, . . . . .65 

• Treatment of Caries, . '. . . 67 

CHAPTER III. 

General Remarks on Filling, . . . . .73 

Materials for Filling — their properties, . . 77 

Lead, ....... 81 

Tin, ...... 81 

Silver, ....... 83 

Platinum, ...... 84 

Gold, 85 

Various Preparations of Gold, . . 87 

Crystal Gold, ..... 88 

Amalgam, ...... 90 

Non-metallic Materials, . . . . .93 

Hill's Stopping, ..... 94 

Os Artificial, ...... 96 

CHAPTER IV. 

Instruments for Filling, ..... 97 

Heavy Cutting Instruments, . . . .97 

Drills, ....... 99 

Bur Drills, . .' . . .99 

Scranton's Drill, ..... 101 

Common Drills, ..... 102 

Drill Ring, 103 

Drill Stocks, ...... 103 



CONTENTS. 



Xlll 



Broaches, 
Excavators, 

Manufacture of Excavators, 
Plugging Instruments, 
The File, 

File Caries, . 

Use of the File, . 

Mode of using the File, 



104 
105 
109 
111 
119 
121 
122 
123 



Separation of the Teeth, . 



CHAPTER V. 



CHAPTER VI. 



Filling Teeth, 

Examination, 
Opening Cavities, 
Removal of Decay, . 
Forming Cavities, 
Drying Cavities, 
Introducing the Filling, . 
Cylinder or Block Filling, 

Forming Blocks, 

Introducing the Blocks 

Pellets, 

Adhesive Foil, . 

The Mallet, . 
Crystal or Sponge Gold, 
Finishing Fillings, 



CHAPTER VII. 

Classification of Decayed Cavities, 

Filling by Classes and Modifications, 
First Class, 

Exclusion of Saliva, 



127 



134 
135 
136 
138 
142 
150 
154 
159 
160 
163 
166 
167 
171 
174 
179 



183 
185 
185 
188 



XIV 



CONTENTS. 



Filling with Foil, . 






195 


Adhesive Foil, . 




. 


196 


Crystal Gold, 


. 




198 


1st Modification, . 






199 


2d Modification, 


. 




201 


Second Class, 




. 


201 


1st Modification, i . 


- 




203 


Third Class, 






205 


2d Modification, 


. 




209 


Fourth Class, . 






210 


1st Modification, 


. 




215 


2d Modification, . 






217 


3d Modification. 






218 


4th Modification, . 




. 


219 


Fifth Class, 


. 




222 


Special Cases, . 




. 


226 


The Palatal portion of the Crown broken 


away, 




leaving the ou 


ter portion standing- 


-nerve 




not exposed, 


. 




227 


Filling large Cavities on the Labial Surfaces 




of the Superior 


Incisor, 


. 


231 



CHAPTER VIII. 



Pathological Conditions, . 
Inflamed Dentine, 
Treatment of Inflamed Dentine, 
Tannin, or Tannic Acid, 
Creosote, or Carbolic Acid, . 
Nitrate of Silver, 
Chlorid of Zinc, 
Terchlorid of Gold, 
Arsenious Acid, 
Alkaline Caustics, 



233 
234 
237 
240 
241 
241 
243 
244 
245 
247 



CONTENTS. 



XV 



CHAPTER IX. 




Exposed Pulps, . . 


. 249 


Treatment of Exposed Pulps, . 


251 


Destruction of the Pulp, .... 


. 260 


, Actual Cautery, 


265 


Potential Cautery, .... 


. 266 


Arsenious Acid, . , . . 


266 


Application of, 


. 268 


Filling Pulp-Cavities and Canals, 


273 


Preparing the Teeth and Roots for Filling, 


. 281 


Dental Periostitis, .... 


290 


Treatment of, . . . ... 


. 293 


. Alveolar Abscess, .... 


297 


Treatment of, . 


. 299 


CHAPTER X. 




Pivot Teeth, 


307 


Fitting the Crown, . ... 


. 311 


Attachment of the Crown, 


314 


Wood Pivots, ..... 


. 314 


Metallic Pivots, .... 


319 


CHAPTER XI. 




Extraction of Teeth, . . . . 


. 325 


General Remarks, .... 


325 


Indications for Extraction, .... 


. 332 


Extracting Instruments, 


334 


The Key, . 


. 336 


Modus Operandi of, . 


336 


The Forceps, ..... 


. 340 


Elevators, ..... 


351 


Hooks, ...... 


. 352 


The Screw, ..... 


353 


The Gum-Lancet, .... 


. 354 


Method of Lancing the Gums, . 


357 



XVI 



CONTENTS. 



Extraction of the Teeth, ..... 


358 


Superior Incisors, ..... 


358 


Superior Cuspids, ..... 


361 


Superior Bicuspids, .... 


362 


Superior Molars, ..... 


365 


Extraction of Roots, .... 


367 


Removal of the Dentes Sapientias, 


368 


Extraction of the Inferior Incisors, 


371 


Roots, . 


372 


Inferior Cuspids, ..... 


372 


Inferior Bicuspids, ..... 


374 


Inferior Molars, . . . . 


375 


Inferior Dentes Sapientiae, . ... 


379 


Extraction preparatory to the Insertion of Artificial 




Dentures, ..... 


380 


Conditions to be observed in the Extraction, . 


382 


CHAPTER XII. 




Accidents in the Extraction of Teeth, 


388 


Hemorrhage, ...... 


389 


Treatment, ...... 


391 


Fracture of the Alveolus, ..... 


400 


Laceration of the Gums, .... 


402 


Breaking the Teeth, ..... 


402 


Removal of a Wrong Tooth, .... 


403 


Dislocation of the Inferior Maxillary, 


406 


Syncope, ...... 


408 


CHAPTER XIII. 




Anaesthetics, . . . . . . . 


410 


Ether — Chloroform, ..... 


410 


Nitrous Oxide, ...... 


415 


Local Anaesthesia, ..... 


416 


Congelation, ...... 


416 


Extraction by Electro-Magnetism, 


420 


Application, ...... 


422 



OPERATIVE DENTISTRY. 



CHAPTER I. 

INTRODUCTION. 

As introductory to the following treatise, a cursory 
consideration of those conditions and diseases of the 
teeth which require the aid of dental surgery, would 
seem appropriate. To refer, however, to all of these, 
or to remark extendedly upon any of them, would 
not be consistent with the design of this work, or 
necessary to a proper understanding of the subjects 
proposed. Only those affections which pertain to the 
teeth directly, and which for the most part, are con- 
fined to the tooth-substance itself, will here be con- 
sidered. Nor will the pathology of contiguous parts 
be introduced ; for the treatment of these, being 
mainly therapeutic rather than surgical, would involve 
a discussion of questions not within the scope of the 
present volume. Indeed, it is proposed merely to 
speak of those affections of the teeth, which generally 



18 INTRODUCTION. 

suggest surgical remedies, and which are implicated 
more or less in the operations described in the follow- 
ing pages ; and first, of 

DEPOSITS. 

In this term are included those calcareous forma- 
tions commonly called tartar, a certain coloring mat- 
ter denominated green or brown stain, and such other 
impurities on the teeth as result from neglect, the use 
of tobacco, and like causes. The word 

TARTAR 

Implies all calcareous desposits upon the teeth. Of 
this substance there are several varieties, the more 
obvious of which have respect to color, composition 
and consistence. In color, there are all shades, from 
a white as light as that of the tooth, or even lighter, 
to a jet black ; and in consistence, all degrees, from a 
thick, gummy mucus, to nearly the density of the den- 
tine itself. The color will, in most cases, be indicative of 
the density, the lightest shade corresponding with the 
softest, and the darkest with the hardest consistence. 
The tenacity to the teeth is also in proportion to the 
density, the dense and dark adhering most firmly. 
The density of the desposit, too, is generally indicative 



TARTAR. 1 9 

of the rapidity of its formation, being in an inverse 
ratio to this. 

All the varieties of tartar are composed principally 
of the same elements, — phosphate of lime, fibrin, fat, 
and animal matter being contained in them all, though 
in various proportions. The fact that some varieties 
are soluble in acids, and others not, has been adduced 
to prove that they are entirely different in their com- 
position. This, however, is accounted for on another 
hypothesis : in the softer varieties, the phosphate of 
lime is so protected by the fat and the animal matter 
that, under ordinary circumstances, acid can not come 
in contact with it; but the dense varieties are very 
soluble, because the acid readily comes in contact with 
the calcareous material. 

Its origin. — It is a precipitate of the saliva, — or at 
least the phosphate of lime, and probably the fibrin, 
comes into the mouth with the saliva ; while perhaps 
the fat and other animal matter are deposited from 
the mucus. In all cases in which this substance is 
formed upon the teeth, the saliva has a definite alka- 
line character, holding in solution the phosphate of 
lime, which, by the action of the acid mucus upon the 
saliva, is precipitated. 

Persons of a lymphatic temperament, or a tendency 
toward it, with muscles of a soft, flabby texture, hair 
light, teeth of a rather inferior quality, and a free flow 



20 INTRODUCTION. 

of saliva, are most subject to the deposition of tartar; 
yet there are conditions of almost all constitutions, 
in which it is freely eliminated. That it is precipi- 
tated from the saliva, is a fact so easily demonstrated 
and so generally admitted, that it need not here be 
considered. 

Points of Deposit. — The points at which salivary 
calculus is deposited in the greatest quantities upon 
the teeth, are in the vicinity of the orifices of the sali- 
vary ducts ; and hence it is found most abundant on 
the lingual surfaces of the inferior anterior teeth, and 
on the buccal surfaces of the superior molars. Fre- 
quently, also, it collects in considerable quantities 
upon the external surfaces of the inferior front teeth. 
The points upon the teeth to which it most readily 
attaches, are at the necks, immediately beneath the 
free margin of the gum, and at the termination of the 
enamel where it is thickest. A nucleus once formed, 
and it encroaches upon the crown of the tooth, if no 
means are employed to prevent its lodgment, at a 
rate determined by the condition of the saliva. 

It is deposited first and most abundantly on the 
necks of the teeth, because here the saliva first comes 
in contact with these organs, and here remains for 
the longest periods and in the largest quantities. 
That it is precipitated very soon after the saliva 
enters the mouth, is evident from the fact that it is 



TARTAR. 21 

found collected upon the superior molars, just in the 
vicinity of the orifices of the ducts-of-Steno, where 
the saliva cannot be retained for any considerable 
time, by reason of the position, but must very soon 
pass along upon the surfaces of the contiguous teeth, 
on which we generally find it deposited in much 
smaller quantities. Indeed, this calcareous material 
has been sometimes found in the salivary ducts them- 
selves. > 

Its Effects. — It exercises no directly injurious influ- 
ence upon the substance of the teeth ; but it is highly 
prejudicial to the parts immediately in connection 
with them, upon which they depend for support. It 
encroaches upon the gums and alveoli, and causes an 
absorption of these important surroundings ; and as 
they become absorbed, its encroachments are con- 
tinued and accelerated. In some constitutions this 
process goes on with little or no annoyance to the 
patient; while in others, irritation, inflammation, and 
even suppuration of the gums occur ; and thus their 
destruction is effected in a twofold manner. This 
irritation and inflammation may extend to the mucous 
membrane, and involve all the adjacent parts. The 
dental periosteum, will usually become implicated in 
the difficulty ; periostitis will ensue, and often sup- 
puration, thus' breaking up the attachments of the 
teeth even before the surroundings are removed. 



22 INTKODUCTION. 

The alveolus, too, becomes diseased, and in some in- 
stances its death and exfoliation result. Salivary cal- 
culus, however, never induces caries of the teeth, nor 
even favors it; except by inducing disease in the 
surrounding parts. On the contrary, we frequently 
meet with instances of decay entirely arrested by a 
deposit of tartar in the cavity. ' 

Persons of all ages are subject to this affection ; 
those past middle life being most so, and those 
advanced in years sometimes having teeth nearly 
covered with tartar. Occasionally to such an extent 

Fig. 1. 




do the roots become invested with it that the teeth 
drop from the sockets. There are some constitutions 
whose diathesis is favorable to a deposition of sali- 
vary calculus through life. Others, again, will be 
entirely exempt from it till some peculiar constitu- 
tional change intervenes, when it will begin to be 
rapidly eliminated. 

Method of removing it.- — The removal of salivary 
calculus is an operation that does not involve a great 



TARTAR. 



23 



amount of skill, but, with suitable appliances, is 
easily performed. There are two methods of effect- 
ing it; the one, that of scaling and scraping, and the 
other, that of decomposing the deposit by the appli- 
cation of an acid. The former is always to be pre- 
ferred; for, in the latter, the chemical action of the 
acid does not stop with a decomposition of the de- 
posit, % but, by the same affinity, and nearly as readily 
attacks the tooth itself. For the successful accom- 
plishment of the operation, instruments of various 
forms and curves will be necessary, adapted and ad- 
justed to the various shapes and situations of the 
surfaces to be operated upon. The most common 
forms are represented in the following figure. The 
blade of the instrument should be applied at a slightly 
obtuse angle with the surface of the tooth, just beyond 



Fiji. 2. 




the edge of the deposit next the gum, and thus slid 
under the tartar, scaling it off to the point, in such a 
manner as not to roughen or abrade the enamel. De- 



24 INTRODUCTION. 

posits of this substance on proximal surfaces of the 
teeth are to be carefully observed, and removed with 
instruments of attenuated blades. When the thick 
incrustations have been thus removed, the surface 
should then be gently scraped, so as entirely to clean 
off all remaining portions, and afterward thoroughly 
polished with fine pumice, or Arkansas or rotten-stone, 
and finished by burnishing. During the operation, a 
frequent employment of the toothbrush with water 
will be required, to cleanse the mouth of the detached 
deposits and the increased secretions; and, in general, 
the completion of the process will occupy more than 
one sitting. Since this deposit often extends beneath 
the free margin of the gum, much care is necessary 
to see that it all be removed. 

GREEN TARTAR. 

This deposit has been so referred to by writers, as 
to convey the impression that it is of the same 
generic character as salivary calculus. Such a mis- 
apprehension is hardly pardonable. The teeth of 
young persons only are subject to this affection, it 
being often found on those of children three or four 
years old ; appears on the labial surfaces of the su- 
perior front teeth, and in largest quantity near the 
margin of the gum. It is seldom seen on the inferior 



GREEN TARTAR. Zb 

teeth, and only on the anterior surfaces of the super- 
ior. The color of this deposit varies from a light 
brown to very dark, inclining to green. Wherever 
it attaches, the surfaces of the teeth are abraded, and 
when it is of long standing, the entire enamel beneath 
it is destroyed, and the dentine is gradually involved 
in the dissolution. This effect upon the teeth is not 
produced by the coloring matter observed upon them, 
but by an acid in combination with this material 
before it is deposited. The stain is a precipitate 
from this compound, and the acid, leaving this, com- 
bines with the calcareous ingredients of the teeth, to 
their detriment as above; but the precipitate is en- 
tirely innocent. 

Its Origin. — Green tartar, or green stain, doubtless 
has its origin in the mucus, when this is in a particular 
acid condition. That it does not proceed from the 
saliva is proved by the fact that it is never found 
where there is a free flow of saliva, or where it has 
free access; but the point of its deposit is where 
the saliva is least frequently present, being most 
abundant in cases in which there is a large relative 
amount of mucus, and this in a very acid condition. 
But the query might arise here, if the mucus of the 
mouth were wholly in that condition, why would not 
the teeth suffer from it elsewhere. Because, on the 
masticating surfaces of the teeth, the friction of the 



26 INTRODUCTION. 

food will prevent it, and on the inner surfaces, the 
friction of the tongue; besides, wherever there is a 
free flow of saliva, this will have a counteracting 
effect. Decay goes on very rapidly, after it has once 
commenced, upon teeth affected by this deposit. 

There are points of dissimilarity between this green 
tartar or stain and salivary calculus, that it may be 
well to notice. The latter is from the saliva; the 
former from the mucus; and hence the one exists 
Avhere there is an abundant flow of saliva, and the 
other where the relative quantity of this is small. The 
calculus is deposited when the saliva is in an alkaline 
condition; the stain, when the mucus is very acid. 
The former is deposited in large quantities and thick 
incrustations, and upon the surfaces of the teeth, and 
is easily removed without detriment to their substance; 
whereas the latter is a thin film, barely sufficient to 
stain the surface, and yet it enters into the tooth- 
substance itself, and cannot be removed without 
detaching some portion of the tooth with it. The one 
seems rather preventive of caries, which does not occur 
beneath it; but the other is highly promotive of decay. 
With these marked features of difference, it is sur- 
prising that the two should ever have been confounded, 
since it is so important that the distinctive character 
of each be understood, in order to its correct treatment. 

Treatment. — In order to a perfect and final remedy 



IRREGULARITY. 27 

for green stain, therapeutic treatment must be com- 
bined with the operative; but only the latter will be 
here described, which has for its object the removal 
of the deposit, and the rendering of the eroded sur- 
face smooth and polished. There are two or three 
methods of accomplishing this object. When the 
erosion is but slight, it will be effected with Arkansas- 
stone, or pulverized pumice and water applied with 
a wooden polisher of the proper form till the stain 
disappears, and with the subsequent use of the 
burnisher with a solution of soap. But when the 
erosion is too extensive to be thus reduced, it must be 
cut down with a file, and then finished with stone and 
burnisher, as before. And when the erosion is extreme, 
a cutting-instrument must precede the file. 

IRREGULARITY. 

By this term we imply those variations from a 
beautiful and natural position, in which the teeth are 
so frequently found. The principal cause of irregu- 
larity is a disproportion between the actual size of the 
arch, and the size required for the accommodation of 
the teeth. When this disproportion exists, the teeth 
which are first erupted, occupy very nearly their 
proper position; but those which come in afterward, 
are more or less disarranged, in proportion to the pre- 



28 INTRODUCTION. 

occupation of the space. There are cases in which 
the roots of the temporary teeth are not absorbed, 
and the permanent teeth are erupted out of their 
true position, even when there is room enough for 
them were the former removed. Irregularity is mainly 
confined to the front teeth, and consists in either 
an inward or an outward inclination, and, in some 
instances, both. Sometimes the incisors are turned 
round in the socket, so that the edge stands at a very 
considerable angle with the proper position. 

The upper teeth are oftener materially disarranged 
than the lower, though the latter frequently exhibit 
some irregularity in front, in consequence of a crowded 
condition. The teeth most liable to be out of position 
are the cuspidate. These, of the teeth of replacement, 
are the last in their eruption; and it often occurs that 
the arch is previously well-nigh occupied; in which 
case they are thrown outward. When there is any 
irregularity of the bicuspids, it is that of an inward 
inclination. The first and second molars are very 
seldom out of proper position. The third molars, 
however, for want of room, are sometimes thrown out 
toward the cheek, or even prevented from coming out 
at all in any direction. 

Effects. — In all cases, irregularity is favorable to 
decay. It is even maintained by some that the organic 
structure of irregular teeth is less perfect than that 



ATROPHY. 29 

of regular, because the former are impeded in their 
eruption, and thus impaired. But this, to say the 
least, is questionable; for it will be remembered 
that the crowns of the teeth are formed and ossified 
before they can be much affected by a crowded state; 
and it is hardly probable that they could be materially 
modified in their structure after this period. The 
crowns of the teeth are rarely if ever deformed by a 
crowded condition. The principal cause of the liability 
of irregular teeth to decay, is the facility they furnish 
for the lodgment of foreign substances about them, 
and the difficulty they present to its removal. And, 
again, in irregular teeth, parts are approximated that 
nature did not intend should be brought together. 
Irregularity impairs the speech, impedes the mastica- 
tion, and often distorts the countenance and deforms 
the features. 



ATROPHY. 

This affection is characterized by defective spots in 
the enamel, white, chalk-like — which scarcely ever 
penetrate the dentine. In these spots there is little 
or nothing of that organic structure exhibited by well 
formed enamel. They are in all cases quite small, 
but vary greatly in number. They are often found 
arranged in transverse rows across the tooth affected. 



30 INTRODUCTION. 

The superior incisors are most frequently found with 
atrophy, though the biscuspids and molars sometimes 
exhibit it. The front upper teeth are attacked by it 
only on the anterior surfaces. 

Instead of the spots we sometimes find pits, or 
indentations, into or through the enamel, which occa- 
sionally run together, so as ultimately to form trans- 
verse grooves of considerable extent upon the teeth. 
In many cases, where on the eruption of the teeth 
the spots only are presented, the organs are not 
injured, except in appearance, the spots retaining 
the smooth, enamel-like surface during life. In other 
cases, the spot is of such a soft, friable texture, that 
it early crumbles out, leaving the little pits above 
referred to. These indentations, however, sometimes 
exist at the first appearance of the tooth, but more 
frequently afterward, being formed by the disintegra- 
tion of the defective portion. 

Atrophy usually occurs on teeth of good structure, 
short, thick crowns, and rather yellowish color. The 
long, thin, white tooth, of imperfect organization and 
insufficient density, seldom or never presents an atro- 
phied condition. 

The Cause. — It may be difficult to point out the 
precise cause of this affection, but some facts in re- 
gard to it are very obvious. There is, in every case, 
an obstruction in the development of the enamel at 



ATROPHY. 31 

the point of defect, and at the time of its origination. 
In some cases, doubtless, there are a deficient amount 
and an inferior quality of the material elaborated for 
the upbuilding of the structure; and this is probably 
the case when the pits exist at the eruption of the 
teeth. In other cases, the requisite quantity of 
material may be elaborated, and yet the vital energy 
be insufficient to organize it, as in the case of the 
spots referred to. The latter condition is more fre- 
quent than the former, as is evidenced by the more 
frequent appearance of the spots than of the pits. 
We are led to infer, then, that the origin of this 
affection is for the most part constitutional, and not 
local. There are commonly found traces of it on all 
the teeth whose enamel was in process of formation 
at the time of the interruption. 

Any general disturbance, such as to interrupt the 
assimilative process, would be detrimental to the per- 
fect formation of the tooth. Again, some affections 
may materially affect the organizing power of the 
system, without interfering with the assimilative 
power. Any disease that should interrupt the func- 
tions of the digestive apparatus, would be prejudicial 
to the process of assimilation; whilst other diseases, 
such, for instance, as those of a febrile character, 
would diminish the vital power, and consequently 
the ability to build up organic structures, without 



82 INTRODUCTION. 

interrupting in any special manner the process of 
assimilation. These things are referred to here for 
the purpose of showing under what circumstances 
atrophy of the teeth may occur. 

Effects. — In the best formed teeth, there are no 
unpleasant results from atrophy, other than its de- 
traction from their beauty. The spots are unsightly, 
and when the pits are present, they become dark, 
and sometimes black, from deposit; which, by ordi- 
nary means, is difficult of removal. In teeth of infe- 
rior structure, decay often supervenes in these pits, 
and, extending thence, involves the other parts ; and 
anything that will affect the tooth-substance, will 
affect the spots in a greater degree. 

EXOSTOSIS. 

This term, critically defined, implies outgrowth from 
a hone; but, as applied to the bones generally, and 
particularly to the teeth, it probably conveys the idea 
of growth upon the lone. The affection thus denomi- 
nated is common to all the bones; some, however, 
being more frequently attacked by it than others. 
It occurs upon the roots of the teeth, but is never 
developed where there is no periosteum. The man- 
ner of its deposit is not uniform ; but it is commonly 
in an enlargement on the point of the root, or from 



EXOSTOSIS. 33 

the point some distance toward, and occasionally all 
the way to, the neck of the tooth. In some cases, it 
extends entirely round the root, and in others, is con- 
fined to one side. It sometimes results in such an 
enlargement of the root, especially if it is near the 
point, as to render the tooth very difficult of removal. 
When it is bulb-form, the entire attachment of the 
tooth may be broken up, so as to allow this to rotate 
in the socket, and yet the tooth be very difficult to 
remove; indeed, in some instances, impossible, with- 
out cutting away a portion of the process. 

The density of the deposit is usually greater than 
that of the root on which it is found; though in this 
respect there is considerable variation : in a few in- 
stances we have found it softer than the root proper. 
The surrounding parts are absorbed for its accommo- 
dation. The color of the substance is slightly yellow, 
not differing much from that of the root itself; and 
frequently it exhibits a semitranslucent appearance. 
The rate of its formation varies considerably, some- 
times increasing so rapidly as to occasion much diffi- 
culty, and at other times seeming to advance very 
slowly ; and frequently it is arrested altogether. 
Roots are often found affected with exostosis, that 
have been dead and crownless for a number of years. 
and yet have never, so far as known, given any trouble 

c 



84 INTRODUCTION. 

because of the affection; and teeth perfectly healthy 
in other respects may be thus affected. 

Its Effects. — It always increases the difficulty of 
removing the tooth, either by enlargement of the point 
of the fang, or by deposit upon one side of it, causing 
it to curve; in which latter case the difficulty is all 
the greater, from the impossibility of determining the 
direction of the curve. It sometimes produces a 
diseased condition of the surrounding parts — in some 
instances chronic inflammation — that may continue as 
long as the tooth remains. Nervous affections often 
result from exostosis, either through irritation caused 
by pressure on the nerve, or through the diseased 
condition of the surrounding parts. The floor of the 
antrum is sometimes absorbed away, in consequence 
of the enlargement of the point of the fang; and then 
disease of the lining membrane of that cavity may 
occur. 

The Cause. — The cause of this affection is not well 
understood. Though much light has been thrown 
upon it by the researches upon the reproduction of 
bone, and especially so far as the function of the 
periosteum is concerned. It is most probably deposited 
by the periosteum when this is in an abnormal condition; 
but what peculiar condition, it is not clearly ascer- 
tained, though some have supposed it to be inflamma- 
tion. It is patent, however, that something more than 



DENUDING. 35 

a state of simple inflammation exists ; for there is in- 
flammation in numerous instances without this deposit. 
Again, in all cases where there is periostitis, that 
state is definitely indicated by percussion upon the 
affected tooth: indeed, in the occlusion of the jaws, 
pain is usually experienced. Yet there are found 
many teeth whose roots are subjects of this deposit, 
that have never given any indications, either by pain 
or otherwise, of a diseased condition. 

This subject is one in which there is room, at least 
so far as dentists are concerned, for extensive obser- 
vation. 

DENUDING. 

This consists in a wasting away of the enamel of 
the anterior teeth, from the points toward the necks. 
The affection, however, is of too rare occurrence to 
demand extended consideration. The color of the 
enamel is not changed by this process, nor is its 
natural polish impaired by any abrasion. The dentine, 
on becoming exposed by this removal of its natural 
protection or covering, is perfectly smooth, but of a 
yellowish cast, in some cases inclining to brown. 
When the enamel is removed, there seems to be a 
cessation of the destructive process; for the crowns 
of such teeth will, in many instances, endure for a 
t 



36 INTRODUCTION. 

long time — indeed, till they are worn down by the 
friction in mastication. 

This wasting process usually begins at the points 
of the teeth, and proceeds toward the necks, on all 
sides, till the enamel is entirely destroyed. Sometimes, 
however, it commences on their labial surfaces; this 
is particularly the case with the superior anterior, 
but very seldom with the inferior teeth. The affection, 
however, attacks the inferior more frequently than 
the superior teeth; yet it is found assailing both with 
about equal energy. 

The cause of the disease is not well understood, 
though it is generally conceded to be the operation 
of an acid contained in the mucus. Doubtless, the 
agent producing the affection is contained in the mucus; 
for it usually occurs where there is a large relative 
amount of this secretion ; but that it is an agent of a 
very decided acid character, we are not prepared to 
affirm. Decay of the teeth does not seem to progress 
with greater rapidity while this affection exists, than 
at other times; and again, the enamel does not present 
the roughened, abraded appearance we find resulting 
from the operation of any ordinary agent. With these 
apparently incongruous facts, it is rather difficult to 
arrive at a definite conclusion as to the precise manner 
in which this condition is produced, or the exact 
character of the agent instrumental in its production. 



CHEMICAL ABRASION. 37 



CHEMICAL ABRASION. 



This consists in a gradual destruction of the entire 
substance of the crown of the tooth — the enamel and 
the dentine. It is an affection of comparatively rare 
occurrence. It assails the superior more often than 
the inferior teeth, though both are subject to it. It 
begins upon the points of the central incisors, wasting 
them away most rapidly at the median line, from 
which it progresses each way, involving the lateral 
incisors, cuspids, and sometimes the bicuspids, so that 
a curved line is presented by the edges of the teeth, 
of greater or less inclination, according to the rapidity 
of the process. When the superior teeth only are 
affected, the opening between the ends of the upper 
and of the lower front teeth, when closed, is a semi- 
ellipsis. If the inferior teeth are affected, as is some- 
times the case, then the opening will be an ellipsis. 

In the case of Mr. Gr., the affection had been in 
process about two years and a half; the wasting away 
extended to the first bicuspids both above and below ; 
and when the jaws were closed, the ends of the upper 
and of the lower central teeth were about one third 
of an inch asunder, and the opening was of the 
elliptical form. It was a mystery to him. Two years 
and a half before, his anterior teeth shut close together 



38 INTRODUCTION. 

on the ends. He had not used them in the mastica- 
tion of his food, for his molar teeth were all good, 
and sufficient for this purpose; and moreover it had 
been impossible for him to use them in mastication, 
since he could not bring them together; and he had 
not been in the habit of putting any hard substance 
between them. 

The Cause. — The cause of this affection, like that 
of denuding, is not well understood. It is supposed, 
however, to be induced by an acid contained in the 
mucus. If this supposition is correct, it must be 
some -acid with whose nature we are but little, if at 
all, acquainted; or, if any ordinary acid, it certainly 
must be modified by very peculiar circumstances, so 
that it effects a solution of both the animal and earthy 
constituents. The surface upon which it acts is always 
perfectly smooth and polished, never presenting that 
roughened and abraded appearance caused by the ac- 
tion of any ordinary acid upon enamel or dentine. 
And again, if this affection results from the operation 
of an acid in the mucus, why does not this acid, to 
some extent at least, affect the teeth at other points? 
Such is not the fact; and caries that has previously 
commenced at other points on the teeth, does not 
progress more rapidly during the existence of this 
disease, than before ; but it certainly would, if there 
were a large quantity of acid in the mucus. 



NECROSIS OF THE TEETH. 39 

It has been supposed that the mucous follicles of 
that part of the tongue which comes in contact with 
the teeth at the affected part, are the agents that 
produce the disease. Of this, however, there is not 
evidence sufficient to warrant an adoption of the 
theory. The cupping of the molars and bicuspids 
bears strong indications of being an analogous pro- 
cess, and yet no such influence can exist for its ac- 
complishment. We have no theory on this subject 
to present, regarding it as still an open field for in- 
vestigation. There can be little doubt, however, that 
the cause of denuding, of chemical abrasion, and of 
cupping, has its origin in the constitution, is not 
merely local, and may be removed, and the affection 
arrested by constitutional treatment. 

NECROSIS OF THE TEETH. 

By this term is understood the death of the part 
affected. It has been remarked that the condition is 
similar to mortification in the soft parts of the sys- 
tem. But in the latter there occurs a change of 
structure; whereas, in the bones, and particularly in 
the teeth, there is not necessarily any structural 
change consequent on the loss of vitality. The teeth 
have their organic connection with the surrounding 
parts by the external and the internal periosteum 



40 INTRODUCTION. 

and the pulp ; their crowns depend chiefly for vitality 
upon the internal organism, as is evident from the 
total loss .of sensibility in them immediately after the 
destruction of the pulp. 

Necrosis of the teeth differs from that of the other 
bones in some particulars, one of the most obvious of 
which is, that in the former there is no exfoliation, 
the living structure not having the power to throw 
off the dead or necrosed portion. Again, a dead part 
in contact with the living, does not materially affect 
it. The roots of the teeth depending for their vi- 
tality upon both their internal and their external 
connections, the former of these connections may 
be destroyed, without materially affecting the latter. 
Thus, a tooth may be partially necrosed, — that is, 
vital in one part and dead in another, — without im- 
mediate injury to the living portion, and without 
separation of the living from the dead. It is a happy 
provision that the analogy between the teeth and 
the other bones does not, in this respect, obtain ; for 
if it did, we should find the crowns of the teeth sepa- 
rated from the roots in all cases, immediately after 
the death of the pulp. 

There results but little change of color to the teeth 
from necrosis, unless coloring matter is absorbed by 
the dentine from the decomposed pulp; though of 
course the lifelike lustre and appearance of the 



NECROSIS OF THE TEETH. 41 

living teeth are not present. Total necrosis destroys 
the entire organic connection of the teeth with the 
surrounding parts; in which case they are immedi- 
ately expelled from their sockets as useless. 

Causes. — Caries is a very common cause of ne- 
crosis, especially the partial form of it to which 
reference is made above. Protracted fever, or dis- 
eases of any kind that diminish the vitality of the 
constitution, will in a corresponding degree diminish 
that of the teeth, and sometimes destroy it entirely. 
Excessive medication, especially with mercurials, will 
sometimes produce partial, and occasionally total ne- 
crosis, as will also sometimes blows or violent shocks, 
when these are not sufficient to displace the teeth. 
Great and sudden changes of temperature have been 
reckoned causes of this affection ; but it may well be 
doubted whether they are adequate, without the con- 
currence of other influences. 



CHAPTER II. 

CARIES OF THE TEETH. 

Notwithstanding the teeth are so important in 
the human economy, having functions so various and 
so extensive to perform, they are greatly neglected 
in most instances, and, in many subjected to positive 
violence; as, for example, in crushing or biting hard 
substances, sustaining weights, and suffering severe 
percussion, sudden extremes of temperature, bungling 
dental operations, etc. Very few give that attention 
to these organs, which is requisite to preserve them 
from injurious influences ; and, owing to artificial 
modes of life, and consequent impairment of health, 
this is often difficult to do. Indeed, these influences 
are frequently not known, and the causes of disease 
in the teeth not explored. 

Such is the truth, to some extent, in regard to 
caries ; though this affection is more generally a re- 
sult of conditions well understood. The dentine is 
affected more frequently by caries than by any other 
form of disease. It is both frequent in occurrence 
and fatal in tendency. Scarcely any that have at- 



CARIES OF THE TEETH. 43 

tained maturity, are exempt from its ravages. It is 
a disease which the vital forces, owing to the nature 
of the tissue, can but feebly withstand, at least with 
far less efficiency than in more highly organized 
structures ; and the restorative process is wholly in- 
operative here. Some maintain that softened dentine 
does in many cases regain its normal density ; but 
this cannot be, unless it retains its vitality. But 
any agent possessed of sufficient energy to decompose 
the dentine, will destroy its vitality. What is that 
decomposition ? Either a lack of vital power to 
maintain the integrity of the organic structure, or 
the action of some agent having an affinity for a cer- 
tain part of the dentine more potent than that vital 
power. In either case, the vitality is destroyed. In 
an organized structure, removal of one of its essential 
constituents occasions a loss of vitality. 

Caries usually makes its first attack upon the den- 
tine, and progresses most rapidly in the direction of 
the tubuli. There are variations from this course; 
as, for example, in the large superficial caries on the 
labial surfaces of the superior incisors. In many 
cases, too, it advances immediately beneath the en- 
amel. Portions of the dentine imperfectly protected 
by the enamel, on account either of an injured con- 
dition or of an imperfect formation of the latter, are 
liable to be attacked by this disease ; and points that. 



44 CARIES OF THE TEETH. 

by their location or any other unfavorable circum- 
stance, retain injurious agents in contact with the 
tooth, are very subject to decay. 

The attack and progress of caries are modified by 
the constitution of the teeth. These may be defec- 
tive either originally or accidentally. Original de- 
fectiveness would extend to all the teeth of the same 
individual, whilst accidental might exist only as to 
some of the teeth in the same mouth, and these only 
at particular points. Such conditions are peculiarly 
favorable for the attack of caries. When the whole 
crown of the tooth is imperfectly organized, the decay 
will advance with uniform rapidity, till the whole is 
destroyed. But when it is only portions of the tooth, 
the caries, after a time, becomes retarded in its pro- 
gress, and in some cases checked altogether. 

Among the circumstances which modify the pro- 
gress of this disease, are, a change of the condition 
or character of the agencies producing it, and an 
increase or a diminution of the amount of such agen- 
cies. The progress of caries will also be governed 
somewhat by the age of the person whose teeth it 
attacks, and by the peculiar constitution of the 
organs themselves ; for, in regard to constitution, 
these present an almost infinite variety, the relative 
proportions of their constituents being exceedingly 
various, even in persons of the same age, and con- 



CARIES OF THE TEETII. 45 

tiimally varying in the same person at different ages. 
There is a constant change going on, the calcareous 
elements increasing, and the animal decreasing. But 
a proper relative amount of elements may be elabo- 
rated, and yet a defective organization exist. This 
condition arises from defective organizing power, or 
from a failure in arrangement and combination of the 
materials; and is dependent entirely on accidental 
causes. In vital energy, indeed, the teeth exhibit 
great diversity; and this corresponds with, and to 
some extent depends upon, the vital energy of the 
general constitution. Dead dentine is decomposed 
more readily than living ; and hence the conclusion 
that vitality resists caries, and that this resistance 
corresponds with the vigor of the vitality. 

The points most frequently attacked by caries, are 
the proximal surfaces of the teeth, the indentations 
and fissures on the masticating surfaces of the molars 
and bicuspids, the longitudinal depressions on the 
buccal and palatal walls of the molars, and the necks 
of the teeth at the termination of the enamel. On the 
proximal surfaces, the enamel is thinner than else- 
where ; and the situation is peculiarly favorable for 
the accumulation and retention of injurious agents. 
The union of the enamel in the fissures and indenta- 
tions of the crowns of the molars, is often imperfect ; 
and thus there is a way of entrance for vitiated fluids 



46 CARIES OF THE TEETH. 

to the dentine. Decay is found at the terminations 
or intersections of these fissures earlier than at any 
intermediate points. The indentations, or grooves. 
on the sides of the teeth, are usually attacked by ca- 
ries at that point next to the neck. Less frequently. 
the disorder is exhibited at the neck, just beneath the 
border of the enamel, under which it barrows with a 
transverse extension. 

The order in which the elements are removed, is 
governed by the nature of the agent which effects the 
decomposition ; and this is usually one having an 
affinity for the calcareous elements strong enough to 
destroy the texture of the dentine, and remove the 
earthy portion. Those acids which have an affinity 
for the lime of the dentine, produce its decomposition 
in this manner. When the decay is thus caused, the 
portion remaining in the cavity is soft, and approximates 
the gelatinous condition as the calcareous material is 
abstracted. Agents of a different character, too. often 
produce decay. Alkalies will act upon the animal 
portion of the dentine, and remove it; and in caries 
thus produced, the residue is friable and chalk-like. 

In other cases the constituents are simultaneously 
removed. Nitric acid will cause an entire breaking- 
up of both the earthy and the animal constituents. 

The dentine outside of the decay may be in an in- 
flamed and irritable condition, so that contact with the 



CARIES OF THE TEETH. 47 

decayed portion will produce pain : and thus we may 
he led falsely to conclude that the softened dentine is 
sensitive; and, indeed, it is maintained that in some 
cases the partially decomposed dentine is so, on the 
supposition that a small portion of the calcareous 
elements may be removed, and yet the vitality of the 
part, not be destroyed. 

The progress of caries is far more rapid in the crowns 
of the teeth than in the roots, for the reason that the 
former are more exposed to the influences of external 
injuries . It is true that the crowns are covered by 
enamel, which is designed to shield the dentine from 
injury, but which is often defective, and on which are 
accumulated agents that it can not resist, even when 
it is perfect ; so that the enamel itself is sometimes 
decomposed. The roots, too, possess a higher degree 
of vitality than the crowns, and their ability to resist 
the encroachments of decay is correspondingly greater ; 
and hence we often find the roots of teeth solid and 
free from decay, the crowns of which have been 
removed by rapid decomposition. Injurious substances 
are sometimes pressed into contact with the dentine, 
through defects in the enamel, or under its projections, 
and there retained till their mischievous effect is pro- 
duced. 

It is maintained by some writers that caries is con- 
tagious. Dr. Koecker was of this opinion. The 



48 CARIES OF THE TEETH. 

question, then, is, whether there is any property i n 
the decayed dentine of one tooth, capable of producing 
the same condition in the healthy dentine of another. 
The residue of abnormal dentine in the soft decay, 
consists of the animal elements and a small portion of 
earthy material; and in decay in which the gelatinous 
constituent is abstracted, the remainder is chalk-like, 
consisting mainly of phosphate of lime. In neither of 
these is there anything that can possibly operate on 
the healthy dentine. There is one thing here, how- 
ever, that is worthy of remark, and that has perhaps 
led to the mistaken notion that caries is contagious: 
decayed dentine will absorb and retain fluids that 
injuriously affect sound dentine; and when the decay 
is on the proximal portion, two teeth are subject to 
the same exciting cause. But it is seldom that two 
teeth thus situated are both in the same stage of decay; 
a fact principally attributable to the difference in their 
constitution. The decay of the teeth in pairs has also 
been adduced as evidence of the contagious character 
of the disease. This, however, results from the fact 
that the pairs are formed at the same time; are subject 
to the same influences in their formation, and hence 
are constituted alike ; and if one of the pair is defec- 
tive, the other will be in a like condition. When there 
is a vitiation of the saliva or mucus, they will be 
similarly affected. In no common acceptation of the 



CARIES OF THE TEETH. 49 

term contagious, can it be applied to caries of the 
teeth. 

The color of caries is exceedingly various, from that 
of healthy dentine, through every intermediate shade, 
to jet black. The rate of the progress is indicated by 
the color of the decay, being slower as this is darker, 
so that when the decay becomes almost stationary, 
the affected portion is usually black. The degrees of 
color are differently enumerated by different writers; 
as, by Koecker five, by others seven, and so on. Three, 
however, are sufficient for our purpose : white, brown, 
and black. The sensitiveness of the dentine is greatest 
in teeth affected by the white decay, and usually 
decreases as the color darkens; though there are 
exceptions to this rule ; for occasionally we find teeth 
affected by dark decay, that are quite sensitive. The 
light-colored decay is more difficult to arrest than the 
dark. In many cases of the former, filling seems 
hardly to retard its progress ; whereas, in the latter, 
by proper filling, the advance of the decay may be 
checked altogether. The cause of the dark color of 
caries is not perfectly understood ; but is probably 
owing to the carbonization of the animal portion. 

The opinion is entertained by some, that this dark 
material protects the dentine from the influence of 
injurious agents. But this is most probably not 
correct, at least to any perceivable extent. If the 



50 CARIES OF THE TEETH. 

deposit does thus serve as a protection, the removal 
of the discolored portion would subject the dentine to 
a renewed attack of caries, which experience assures 
us it does not do, hut that after some time it assumes 
the dark hue again. Those who maintain this opinion, 
refer, in support of it, to the fact that a deposit of 
oxyd of silver being made upon a decay of light color, 
)Sy the use of nitrate of silver, the progress of the 
decay is thereby retarded. This retardal, however, 
is effected more probably by a change in the character 
of the decay, than by any protection afforded by the 
coating of oxyd of silver. 

Some sensitiveness commonly accompanies caries. 
It does not often amount to pain, but is rather a sense 
of uneasiness; yet from change of temperature or 
contact of acids or hard substances, intense pain may 
be produced. Dr. Koecker remarks that caries is 
most tender in its first stages; and Dr. Cone, that 
when a tooth is attacked by it, the sensitiveness is 
increased. The surface of the dentine, or that part 
united to the enamel, is susceptible of the most 
acute sensitiveness, this being on the periphery of 
the vital force. When there is inflammation of 
the dentine, intense pain may be produced by the 
contact of an instrument, in a cavity of decay, at the 
line of union of the dentine with the enamel, and very 
little sensitiveness be present elsewhere in the cavity. 



CARIES OF THE TEETH. 51 

Sensitiveness of a uniform character sometimes 
pervades all parts of the cavity, while at other times 
it may be very intense at one point, and very slight 
or entirely absent at any other. A thin lamina of the 
dentine lining the whole cavity, may be uniformly 
sensitive, and in some cases this sensitiveness may 
involve the entire body of the dentine. 

By means of this sensitiveness, warning is trans- 
mitted to the pulp, which emits osseous material with 
increased energy; and thus a process of rilling up the 
natural cavity of the tooth is instituted, that the decay 
may not encroach upon the pulp. But this warning 
may, in some degree, be transmitted to the pulp, 
though there be no increase of sensitiveness. 

This sensitiveness is modified by the character of 
the teeth, the nature of the decay, and the state of 
the patient's constitution. The teeth of the same 
person will be more sensitive at one time than at 
another, because of a greater irritability of the nervous 
system. Those teeth which decay most rapidly, are 
usually most sensitive; though in teeth whose vitality 
is lost considerably in advance of their decay, there 
is no sensitiveness at all. Except in such cases as 
last mentioned, the whitest and most rapid decay has 
most sensitiveness, the brown much less and the black 
scarcely any. 



52 CARIES 0E THE TEETH. 

CAUSES OF CARIES. 

The causes of caries of the teeth may be considered 
under two general divisions — predisposing and ex- 
citing. Of the former some are original, others 
accidental. The original development of the consti- 
tution may be defective, either from original or from 
accidental defect in the parent; but more certainly 
from the former. Constitutional characteristics are 
transmissible, and a defect is as surely hereditary as 
anything else. In the fetus, during gestation, there 
may have originated germs from which perfect organs 
can never be developed, and these germs may be 
more or less defective according to the constitutional 
condition of the mother, or according to accidental 
conditions to which she may be subject, and which 
may seriously affect the fetus. After birth, too, the 
child is exposed to injurious impressions, which will, 
to a greater or less degree, render the development 
defective ; as imperfect nourishment and the diseases 
and functional derangements peculiar to childhood. 
A diseased condition, or functional derangement, will 
interrupt the proper elimination and perfect upbuild- 
ing of the materials necessary for the perfect struct- 
ure; and indeed anything that will disturb the 
equilibrium of action in the system, may be detri- 
mental to the teeth. 



CAUSES OF CAIIIES. 53 

In some instances the teeth will exhibit :he pecu- 
liarities of the mother, and in others, those of the 
father ; while sometimes they similate those of both 
parents ; and when the parental imprint is thus found 
stamped on the teeth, it will also be found that those 
of the same class decay at the same points and at 
about the same age as in the parent. In such cases 
the defect is manifestly hereditary ; it cannot be acci- 
dental : the coincidences thus constantly occurring 
preclude any other conclusion. Hereditary taint, then, 
may be regarded as a predisposing cause of caries. 

Impaired vitality is another predisposing cause ; 
and not only impaired vitality of the teeth and con- 
tiguous parts, but also that of the general system. 
Indeed, the vital vigor of the teeth depends upon 
that of the general system, and, when there is no 
local adverse influence at work, corresponds with it ; 
so that when the general system is in the most healthy 
condition, the teeth possess the greatest power of re- 
sistance to deleterious agencies. This resisting power 
is, at best, comparatively feeble ; but its feebleness is, 
to some extent, compensated by the peculiar structure 
of the teeth, which are less liable to decomposition 
than any other part of the human body. Yet the 
integrity of these organs depends much on the main- 
tenance of a healthy vitality, and this on that of the 
general system. A dead tooth will decay far more 



54 CARIES OF THE TEETH. 

rapidly than a living one in similar circumstances ; 
and hence the conclusion that vitality resists inju- 
rious agents, and that the resistance will be in pro- 
portion to the vitality. 

All febrile conditions promote and facilitate decay, 
and frequently in two ways : by diminishing the 
general vitality, and by changing the secretions of 
the mouth so that these act injuriously upon the 
teeth. Accompanying such conditions, there is gene- 
rally inflammation of the dentine ; and in such cases, 
this always partakes of the general disorder so as to 
become very susceptible to injury. All diseases, 
indeed, that impair the vitality and change the secre- 
tions, may be considered predisposing causes of decay, 
and some even more ; dyspepsia, for instance, being 
not only predisposing, but also exciting, since it pre- 
pares in the stomach an acid that is almost continu- 
ally thrown upon the teeth, and that acts upon them 
with great energy. Residence in miasmatic regions, 
is also a predisposing cause, inducing unfavorable 
conditions. 

Diminished vitality may result either from consti- 
tutional or from local causes. These latter are such 
as produce an irritable or diseased condition of the 
contiguous parts, or an abnormal condition of the den- 
tine, without the power to effect its decomposition. 
Local causes of a diminution of vitality are not in 



CAUSES OF CARIES. 55 

their character so formidable, and not so difficult to 
control, as those which are constitutional. 

Many medicinal agents are regarded as predis- 
posing causes of caries ; and among these, mercurials 
occupy a prominent place. They operate by vitiating 
the secretions of the mouth, and producing an abnor- 
mal condition of the periosteum about the fangs of 
teeth, the mucous follicles, and the salivary glands. 
Some entertain the opinion that the abnormal action 
of the absorbents, induced by mercurials, predisposes 
to decay. 

Dental operations performed at an improper time 
and in an improper manner, may be reckoned among 
the predisposing causes of caries. The vitality of tho 
teeth may be thus impaired, or a diseased condition 
established, or the part operated upon may be per- 
mitted to remain rough, so that foreign substances 
will be retained, and, becoming vitiated, produce a 
deleterious effect. Often, from an improper use of 
the file, extensive inflammation of the dentine super- 
venes, which is sometimes followed by death of the 
tooth, and by disease of the contiguous parts. Arti- 
ficial substitutes imperfectly adapted, are, in many 
instances, the occasion of caries ; not that clasps or 
the edges of the plate tend directly to injure the 
tooth, but the agencies superinduced by them do, 



56 CARIES OF THE TEETH. 

and especially when the material used is not of the 
right quality. 

Lack of proper exercise in mastication induces a 
condition favorable to decay, both by favoring the 
action of injurious agents upon the teeth and by with- 
holding the stimulus of normal exercise. Tartar and 
other deleterious substances are much more rapidly 
deposited when the teeth are idle. 

The teeth cannot, with impunity, undergo great and 
sudden transitions of temperature, or even such vari- 
ations as may be endured by the surrounding parts. 
By these, inflammation of the dentine may be induced, 
and the vitality of the teeth diminished. And in 
friable teeth, checking of the enamel may occur, and 
thus a condition arise that will facilitate decay. 

EXCITING CAUSES OF CARIES. 

When there is a predisposition to caries, any of the 
exciting causes act with more effect. Well organized 
teeth of unimpaired health and vitality, withstand 
influences that, in less favorable circumstances, des- 
troy them in a very short time. The immediate 
cause of decay is the action of agents chemically upon 
the teeth. It is not here proposed to enter upon an 
investigation of the manner in which these various 
agents operate ; for that would open up a vast field 



EXCITING CAUSES OF CARIES. 57 

for exploration — a field outside of the province of 
this work. The sources of these, however, are sev- 
eral : as, vitiated secretions of the mouth ; the saliva, 
and the mucus ; abnormal secretion from the stomach ; 
decomposition of animal and vegetable substances in 
the mouth ; acids taken with food, or administered as 
medicines ; and galvanic action. 

The natural state of the mucus is acid, but that of 
the saliva alkaline ; so that these secretions counter- 
act each other ; but when the saliva and the mucus 
are both acid, the teeth must suffer. These secre- 
tions may become vitiated, through inability of the 
glands, from disease or an enfeebled condition, per- 
fectly to perform their functions ; or the blood may 
be in an abnormal state, and the glands unable, on 
that account, though they were healthy, as they 
seldom are in such case, to elaborate healthy saliva : 
when the fountain is corrupt, the stream cannot be 
pure. Thus, anything that produces a diseased con- 
dition of the blood, tends to the decay of the teeth ; 
and such diseased condition often has a direct injurious 
effect on the secretive apparatus, and so works a 
double harm. 

But to the theory of the pernicious influence of the 
saliva, it may be objected, that, if it were true, all 
parts of the teeth would be alike affected. This 
objection, however, will loose its force when it is con- 



58 CARIES OF THE TEETH. 

sidered that the teeth, in many cases, are not equally 
well organized in all their parts ; that some parts are 
not so well protected as others ; and that between the 
teeth there is room for the retention of saliva and 
foreign substances, which there combine their influ- 
ence upon them. In cases in which there is a great 
quantity of viscid saliva constantly flowing, the teeth 
decay very rapidly. The decay is of a light color ; 
so light, indeed, that, in many instances, it is difficult 
to distinguish it, by this, from undecomposed dentine. 
The gastric fluid often becomes deranged by irrita- 
tion or disease of the stomach, so that the function 
of the latter is very imperfectly performed, and fer- 
mentation of the food occurs, evolving agents that 
injuriously affect the teeth. In dyspepsia, such agents 
are often brought in contact with the teeth by eructa- 
tion and vomiting; and the diseased gastric fluid, 
which contains a large proportion of hydrochloric acid, 
is also thus brought in contact with them, acting upon 
them with great violence. After food commingled 
with this secretion is ejected from the stomach, the 
teeth will be found eroded over all their surfaces. 
Dyspeptics will appreciate this remark. In such 
cases, if the teeth are not of superior organization, 
they are destroyed in a short time. Their surfaces 
thus roughened, afford a lodgment for foreign sub- 
stances on all parts. 



EXCITING CAUSES OF CARIES. 59 

The most common agents, however, that injure the 
teeth, are originated in the mouth, by the decompo- 
sition of animal and vegetable matter. By this pro- 
cess, elements are eliminated, that form new combi- 
nations and these operate with energy in the 
destruction of the teeth. Favorable conditions exist 
in the mouth for such decomposition, and also for 
such new combinations ; for there is a sufficient amount 
of heat and moisture; for both of these, especially 
the former, facilitate the action of any acid upon the 
dentine. The character of the saliva and mucus will 
very much modify the decomposition of foreign sub- 
stances in the mouth. If these secretions are both 
acid, the decomposition will be much more rapid, and 
more potent in its effect. 

Again, it is sometimes the case that the salivary 
glands are comparatively inactive, except when spe- 
cially excited, and yet the mucous glands still effi- 
cient, eliminating their secretion; so that the mouth 
assumes an acid condition, because there is not saliva 
sufficient to neutralize the mucus; in which condition 
decomposition of foreign substances would be greatly 
accelerated. There are many cases, however, in which 
the flow of saliva is copious, and yet the decay very 
rapid; which is in consequence of an acid condition of 
both secretions, or of a rapid decomposition of foreign 
substances in the mouth. 



60 CARIES OF THE TEETH. 

There are acids taken with the food that act di- 
rectly upon the teeth; as acetic acid, or vinegar. 
Professor Westcot says: " Acetic and citric acids so 
corroded the enamel in forty-eight hours, that much 
of it was easily removed with the finger-nail." And 
"Malic acid, or the acid of apples, in its concentrated 
state, also acts promptly upon the teeth." Now, these 
acids, in the use of many kinds of food, are brought 
into frequent contact with the teeth. In the manufac- 
ture of vinegar, sulphuric acid is often employed; so 
that in this article of food we have that acid either 
alone or combined with the acetic, the former acting 
with greater energy upon the teeth than the latter. 
Acetic acid also facilitates the fermentation of food 
retained in the mouth, and thus reproduces itself in 
abundance. 

After eating apples that contain a great amount of 
malic acid, the teeth will be found corroded over all 
their surfaces. This acid, as well as the others, affects 
the enamel somewhat, and when the latter is very thin, 
though it may not be all removed from any particular 
point, yet its integrity will be destroyed, so as to be 
readily fractured, thus admitting injurious agents to 
contact with the dentine, which is much more suscepti- 
ble of injury from acids than the enamel: points 
imperfectly protected by this are violently attacked 
by acetic, malic, and sulphuric acids. In decayed 



EXCITING CAUSES OF CARIES. 61 

cavities these agents produce rapid results. They 
should be as much as possible avoided, and, when 
necessarily used, should be removed from the teeth 
by cleaning with great care. It would be safest to 
employ some neutralizing agent after the use of any 
acids with food. During mastication, there is an 
increased secretion of saliva, which, if in a healthy 
state, w T ill tend to neutralize any acid that may at the 
time be present, and also, by its flow, to remove 
foreign substances from the mouth. 

Salts may be decomposed in the mouth, and their 
acids act upon the teeth; as when the acid of the 
salt has a stronger affinity for any element of the tooth- 
bone than for the base with which it is combined. 
Many medical preparations contain agents peculiarly 
deleterious to the teeth; acids being especially in 
requisition for these, and oftentimes in considerable 
quantities. The acids most commonly thus adminis- 
tered are the hydrochloric, the nitric, the sulphuric, 
the acetic, the tartaric, and the citric, any one of 
which will produce direct and rapid decomposition of 
the dentine, even when unaided by the temperature of 
the mouth. These acids are often administered by 
physicians, without any regard to their nature or 
their influence upon the teeth. Sometimes, however, 
they are given through a tube; though this method 
generally does not amount to much as a precautionary 



62 CARIES OF THE TEETH. 

measure ; for in most instances the fluid comes in 
contact with all parts of the mouth. A subsequent 
rinsing of the mouth with water effects only a dilution, 
not an entire removal of the acid. In order wholly 
to counteract their injurious influence upon the teeth, 
an alkaline solution should be used after the adminis- 
tration of such medicines. 

Galvanic action is a cause of decay of the teeth, 
only so far as it is a means of decomposing com- 
pounds in the mouth, and the elements of which, 
according to the laws of affinity, form other com- 
pounds, prejudicial to the teeth. The elements hy- 
drogen, nitrogen, and oxygen, may thus be set free 
from animal and vegetable substances, when they will 
at once seek other elements with which to combine ; 
and the character of the combinations will be deter- 
mined by the nature of the elements, and by the 
attendant circumstances. These compounds will fre- 
quently be of an acid character. 

Such an arrangement may exist as will maintain a 
constant galvanic action, whose legitimate effects will 
be as constant upon the teeth ; and this ceaseless 
process cannot but make its mark. It is a favorable 
arrangement for galvanic action when there are two 
or three kinds of metals in the mouth at once, par- 
ticularly if these are such as differ in their affinities 
for oxygen, and in their electric conditions. In some 



COMPARATIVE LIABILITY TO HECAY. 63 

cases three, or four kinds of metals are employed in 
filling teeth of the same mouth ; in some, fillings of 
one metal and a plate of another ; and in others, plates 
of so low a carat are used that they oxydize rapidly 
in the mouth, without the aid of any other metal. 

COMPARATIVE LIABILITY TO DECAY. 

All classes of teeth are not alike liable to decay. 
Their difference in this respect may arise from a dis- 
similarity in their organic structure, the best organized 
being the most capable of resisting disease ; or from a 
concentration of the destructive agency upon the 
tooth first affected. The first molars are much more 
liable to decay than any other teeth, since they are 
less perfectly developed than those formed at a later 
period of life. They are the first permanent teeth 
erupted, and are subjected to all the irritating condi- 
tions consequent on the removal of the temporary, and 
the development and eruption of the permanent teeth. 
But these conditions, in many cases, produce no ap- 
parent injury upon them, they maintaining their integ- 
rity till all the other permanent teeth appear, and then 
decaying earlier than any others. In such cases, 
the decay is a result of influences more potent than 
those occurring on the eruption of the other teeth. 

After the first, the second molars are most subject 



64 .CARIES OF THE TEETH. 

to caries; and after these the second bicuspids. The 
latter two classes doubtless are so subject, more from 
the facility they afford to the lodgment of deleterious 
substances, than from a relatively imperfect organiza- 
tion. Besides, from six to fifteen years of age, the 
teeth are less appreciated and less cared for than at 
a later period of life. The next most liable to decay 
are the third molars. Then follow in order the first 
bicuspids, the lateral incisors, the central incisors, and 
the cuspids. Below are appended, in tabular form, 
one thousand cases of decayed teeth, as observed 
under ordinary circumstances, exhibiting the number 
and per cent, of these in each class : — 

26, or 2J per cent., in central incisors. 



38, or 3| 


a 


in lateral incisors. 


24, or 21 


(< 


in canines. 


87, or 8f 


" 


in first bicuspids. 


134, or 13i 


a 


in second bicuspids. 


370, or 37 


a 


in first molars. 


218, or 22f 


a 


in second molars. 


102, or 10i 


" 


in third molars. 



Of these, a large proportion were removed for relief 
from disease originating in caries of the dental tissue. 
In general, the superior teeth are liable to decay 
earlier and more rapidly than the inferior. 



CONSEQUENCES OF CARIES. 65 



CONSEQUENCES OF CARIES. 



It is here proposed to refer only to some of the 
more common results of this affection, one of the 
most obvious of which is the exposure of the pulp of 
the tooth; on which exposure, disease ensues, and 
finally death. During this diseased condition of the 
pulp, there occurs that very peculiar sensation com- 
monally denominated toothache. As well as the 
destruction of the pulp, the entire destruction of the 
crown of the tooth is the inevitable consequence of 
caries, unless arrested in its progress. After the 
destruction of the pulp and the lining membrane, 
the external periosteum in many cases becomes 
involved, the affection being but an extension of 
that which destroyed the internal periosteum. In- 
flammation and suppuration are of common occur- 
rence, by which a discharge is established from be- 
tween the margin of the gum and the neck of the 
tooth, or through a fistulous opening in the process 
and the gum, as is the case when an abscess is formed 
at the point of a root. 

A diseased condition of the alveolar process is, in 
many instances, produced by diseased and dead teeth ; 
necrosis and exfoliation of considerable portions being 
sometimes the result. Indeed extensive caries o^ 



66 CARIES OF THE TEETH. 

the jaw is occasionally thus produced. Disease of 
the antrum, too, is very generally induced or greatly 
aggravated by the same cause. Tumors, sometimes of 
a malignant character, connected either with the bony 
or with the soft parts, not unfrequently spring from 
this source, particularly in constitutions of a cancerous 
diathesis. Great nervous derangement may result, 
either in whole or in part, from decayed teeth, as does 
very frequently facial neuralgia, which is sometimes 
confined to a single nerve-branch in the immediate 
vicinity of the irritating cause, sometimes ramified 
over the whole side of the face and head,, and occa- 
sionally spread much farther, so as even to implicate 
the shoulder and the arm. Neuralgia of these, ex- 
tending down to the hand, is often found to be in- 
stantly relieved by extraction of a diseased tooth ; 
and any operator of much observation can call to 
mind numerous instances in which facial neuralgia 
has been thus relieved or wholly cured. This affec- 
tion of the face, however, does not always originate 
in diseased teeth ; though there is little doubt that, 
in a majority of cases, it rises wholly or partially from 
this cause. 

Inflammation of the mucous membrane of the mouth, 
is a common result of diseased teeth ; and it is liable 
to extend to distant parts of this membrane, and 
occasion greater difficulty than in the mouth, as 



TREATMENT OF CARIES. 67 

would especially be the case when there is an irri- 
table condition of the throat and bronchia ; and the 
esophagus and stomach are not exempt. In what 
degree such an implication of the respiratory and the 
digestive apparatus is referable to diseased teeth, it 
may not be easy to determine ; but it is impossible 
that a number of such teeth, involving in their disease 
all the ramifications of the facial nerves and the 
whole mucous membrane of the mouth, could remain 
there with impunity. And besides this direct influ- 
ence on the lungs and stomach, diseased teeth are 
constantly emitting offensive odors, which are taken 
in by inhalation, and offensive matter, which is swal- 
lowed with the food. 

TREATMENT OF CARIES. 

In the rational treatment of caries, the first con- 
siderations are the nature and peculiarities of the 
obvious predisposing causes ; whether these are con- 
stitutional or local ) and if constitutional, whether 
they are such as can be modified by therapeutic 
treatment of the general system. If the latter, such 
treatment should be adopted as will bring about the 
most perfect state of health, so as to obviate as far as 
possible all conditions favorable to decay, by securing 
a healthy condition of the mouth in all its parts — as 



68 CARIES OF THE TEETH. 

the gums, the mucous membrane, and the salivary 
glands. The teeth should be kept free from all de- 
posits and accumulations of whatever character ; for, 
though some of these may not affect the teeth directly, 
yet they induce disease of the surrounding parts, and 
thus indirectly exert a pernicious influence upon 
them. 

The foregoing remarks, however, refer rather to 
the prevention of decay than to its treatment after it 
actually exists. Yet they are, on that account, none 
the less important, since here, as elsewhere, preven- 
tion is better than remedy. But they apply to such 
prevention as well after decay has commenced as 
before, if the ultimate object is preservation of the 
teeth. After the first attack, the teeth are more 
vulnerable, and less capable of resistance. 

When decay has attacked a tooth, the treatment 
depends upon the nature and extent of the disease. 
Rapid decay requires more prompt and energetic 
treatment than that of slow progress. Remedies 
that would be appropriate and efficient in the one, 
would be quite inapplicable to the other. The per- 
sistence of caries is not always in proportion to its 
rate of progress. We sometimes find teeth in which 
the decay is not advancing rapidly, and thence are 
led to conclude that it may be easily arrested ; the 
affected part, if superficial, is removed, and the den- 



TREATMENT OF CARIES. 69 

tine thoroughly polished ; and yet after a time, decay 
again attacks the tooth at the same point. Or, where 
the caries has penetrated the tooth, so that it re- 
quires filling, though it is skillfully filled, and the 
plug and tooth carefully polished, yet in many in- 
stances the dentine soon softens about the border of 
the plug. 

The extent and nature of the decay will suggest the 
mode of treatment. Superficial caries on some parts 
of the teeth may be remedied and removed by cutting 
away the portion implicated in the disease, dressing 
with a fine file, polishing with Arkansas, Scotch, or rot- 
ten stone till the file marks disappear, and then apply- 
ing the burnisher very thoroughly to the entire surface 
operated upon. Afterward, the most careful atten- 
tion to cleanliness is requisite, to prevent a recur- 
rence of the attack. This treatment is applicable to 
decay upon proximal surfaces; but in the depressions 
of the masticatory and buccal surfaces of the molars, 
it is not practicable. 

Sometimes the dentine, at points where it is ex- 
posed, gives warning, by acute sensitiveness, of 
threatened decomposition, before there are any other 
indications of it, thus evidencing the presence of 
some very irritating agency promotive of decay. 
Such points should receive prompt and strict atten- 
tion, and the increased sensitiveness be immediately 



TO CARIES OF THE TEETH. 

subdued ; as it may be, by the use of some prepara- 
tion that will counteract the exciting influence — some 
dentifrice or lotion containing an alkali ; or a rubbing 
of the sensitive surface with a smooth steel burnisher, 
will in many cases effect this object, and prevent the 
development of decay. 

It has been suggested that the character of the 
caries may be modified by the local application of 
therapeutic agents — that the rapid decay may be 
changed to the slow — and this, too, without regard 
to the attendant circumstances,, such as the condition 
of the secretions of the mouth, the causes producing 
the disease, etc. ; for this purpose various agents have 
been proposed. It is held that by an application of 
the nitrate of silver, the white, rapid decay being 
changed to that of a dark color, is arrested in its pro- 
gress. But there is no very palpable principle on which 
this agent can be supposed to operate to arrest caries. 
It is generally conceded to be injurious to a healthy 
tooth ; how, then, it becomes beneficial to one de- 
cayed, it is not easy to perceive. The notion may 
have originated in the fact that, after the application 
of nitrate of silver, the cavity turns dark, or black ; 
and this color being naturally associated with the 
slow form of decay, it may have been concluded that 
it might be thus associated by artificial means. This 
conclusion, however, is fallacious; for the coloring 



TREATMENT OF CARIES. 71 

matter being the oxyd of silver deposited on the 
walls of the cavity, is wholly foreign, and holds no 
necessary relation to the kind of decay, or to the 
agency producing it. The deposit may possibly serve 
as a temporary shield to the dentine beneath, but 
only temporary ; whereas, on the other hand, it will 
be remembered that nitric acid is liberated by the 
decomposition of the nitrate, and operates destruc- 
tively upon the tooth-bone. An ethereal solution of 
the terchloride of gold has also been suggested as a 
preventive application. Its operation would be much 
the same as that of the nitrate of silver, and equally 
inefficient. Preparations to neutralize and counteract 
the effects of deleterious agents upon the teeth have 
been recommended as topical applications. These 
are such as possess alkaline properties. But anything 
of this kind would require frequent application ; in- 
deed, it would be necessary to keep the affected part 
constantly under its influence, as long as the sur- 
rounding conditions continued to favor decay. 

Though nothing of this kind can be relied upon 
permanently to arrest caries, yet, in many instances, 
much benefit is to be derived from local treatment. 
Alkaline topical applications will, in many cases, 
alleviate the most acute sensitiveness of the dentine ; 
accomplishing this, no doubt, by their neutralizing 
influence upon the irritating agents. Many opera- 



72 CARIES OF THE TEETH. 

tors employ simply the bicarbonate of soda for this 
purpose, with the happiest results. As another class 
of topical applications to check or modify caries, 
those have been suggested, which will form an insol- 
uble compound with the gelatinous or animal portion 
of the tooth ; such as tannin, creosote and some of the 
essential oils. The only effect of these, however, is, 
to form a shield or protection over the structure be- 
neath : there is, of course, no change effected in the 
conditions or agencies which produce the decay. 



CHAPTER III. 

GENERAL REMARKS ON FILLING. 

The importance and value of the operation of fill- 
ing are obvious, from various considerations. It is 
one that is in frequent requisition. It is the only 
treatment for deep-seated caries : by it, the disease is 
arrested and the lost part restored, so far, at least, as 
it can be by a foreign substance. There is no mate- 
rial similar to that destroyed — no substance possess- 
ing the characteristics of the lost portion of the tooth 
— with which to effect the restoration. Under favor- 
able circumstances the operation of filling is efficient 
in arresting caries and restoring the lost portion of 
the tooth. In order, however, that it be permanent 
in its character, the case needs to be attended with 
favorable conditions, and the work to be thoroughly 
done. But, two similar operations, both equally well 
performed, may result very differently as to ultimate 
success in preserving the teeth to which they may 
have been applied ; the one effectually preventing 
further decay, and the other seeming to interpose to 
it but little obstacle. Indeed, the probabilities of 



74 GENERAL REMARKS ON FILLING. 

such success in different operations, equally well ac- 
complished, cannot be calculated, without consider- 
ing a variety of circumstances, such as differences in 
constitutions, in states of health, in previous and sub- 
sequent habits. 

The rilling of the teeth is predicated upon the na- 
ture of decay, upon the fact that the lost portion will 
not be restored by nature, and upon the fact that 
caries is an effect of external causes, and not of any 
cause within the tooth itself. If the cause of caries 
were alone within the tooth, then rilling would not 
be its rational treatment. The organic structure of 
the teeth is of such nature that no change to the ex- 
tent of decomposition will take place in it, indepen- 
dently of external influences. Any organ possessing 
sufficient vitality and circulation to be susceptible of 
disease and decomposition, independently of external 
influences, possesses recuperative power enough to 
restore to itself a lost part ; and if dentine could be 
decomposed without external agents, the introduction 
of any foreign substance whatever into the cavity, 
would certainly not arrest the decay, but most pro- 
bably accelerate it. If it is true that the decay of 
the teeth ever originates in constitutional causes, 
then the treatment should be constitutional, and not 
local. 

The filling of teeth, then, is based upon the ina- 



GENERAL REMARKS ON FILLING. 75 

bility even of healthy dentine to resist the encroach- 
ment of decay. As preliminary to the operation, all 
the circumstances, both direct and collateral, should 
be carefully noted in every case, and the course of 
treatment should conform to the indications thus ob- 
served. The constitution, temperament, and health 
of the patient; the peculiarities of the teeth; their 
susceptibility of decay ; their present condition, and 
that of the parts about them; the periosteum, the 
gums, the mucous membrane, the secretions of the 
mouth, the saliva, and the mucus, should all be 
closely considered; for only on a correct diagnosis 
can a proper treatment be based. Every operation 
should be performed as completely as, under the cir- 
cumstances, is possible. Indeed, every step in the 
operation should be perfect, before a successive one 
is attempted. All the instruments employed should 
be unexceptionable in material, form, and condition ; 
inferior instruments should find no place in the case 
of the dental operator. The material for filling 
should be of the best quality and prepared in the best 
possible manner. Not that material for filling should 
be prepared in only one way; for some materials, 
gold for instance, may be prepared in three or four 
different forms^ each perfect in its kind, and efficient 
in the hands of the expert manipulator. While with 
instruments and material all in the most perfect con- 



76 GENERAL REMARKS ON FILLING. 

dition, and with a thorough cognizance and apprecia- 
tion of all the attendant circumstances, our most skill- 
ful operators barely attain success, need we be aston- 
ished that the man ignorant of all these circumstances, 
and possessed of only a few crude, ill-conditioned 
instruments and materials, the nature of which he does 
not understand, fails in almost every essay ? 

Much depends on therapeutic treatment ; not, in- 
deed, to restore parts already lost, or to restore to 
health parts much diseased, but to avert a tendency 
to disease in parts but feebly organized. This treat- 
ment may be either constitutional or local, or both ; 
but constitutional when there is indicated any idio- 
syncrasy favorable to decay. If, however, the whole 
difficulty is local, topical treatment only is required. 
What the special treatment should be in either case 
will be more fully considered hereafter. Compara- 
tively little can be accomplished by local application 
to the substance of the tooth ; but the parts contigu- 
ous, as the gums and the mucous membrane, may be 
thus treated, with an assurance of more signal results. 

Though in the teeth nature does not assist to re- 
store a lost portion, as in those parts more highly 
organized, yet, to compensate in some degree, the de- 
structive process is far less rapid in the former than 
in the latter. The general surgeon depends much 
upon nature for the success of his operations ; for, 



\ 



MATERIALS FOR FILLING. 77 

though he perform them unskillfully, yet the kind 
energy of nature is always present to assist him ; but 
in this specialty the practitioner must necessarily. de- 
pend more upon his skill, and less upon the curative 
efforts of nature ; though much more reliance is placed 
upon it now than formerly. 

MATERIALS FOR FILLING. 

In the selection of materials for rilling teeth, there 
are some important considerations that should be 
kept constantly in view; the first and principal of 
which is to choose that kind which will protect the 
tooth from further decay — protect the affected part 
against the influence of those agencies on which the 
disease depends. A material or class of materials 
should be selected that would not, under any circum- 
stances, operate either as a local or a constitutional 
injury. There are several properties that materials 
for filling teeth should possess, one of the most impor- 
tant of which is indestructibility. Any substance, 
whether simple or compound, that will not maintain 
its identity and integrity when subjected to any con- 
ditions of the mouth, is wholly unfit to be used as a 
material for filling. If compounds are employed, they 
should be such as would not be affected by the secre- 
tions of the mouth, or by any attendant conditions. 



78 GENERAL REMARKS ON FILLING. 

A mere mechanical mixture would not be an appropri- 
ate material for permanent rilling ; and all compounds 
of the metals, so far as we are familiar with them, are 
unfit for this purpose, by reason of the facility with 
which they are destroyed in the mouth. 

The next most important property of a material 
for filling is adaptability ; by which is meant a capa- 
bility of being wrought into suitable shapes for the 
purpose, — a facility of being applied and conformed 
to the parts upon which it is to be placed. There 
are substances that would be entirely indestructible 
in the mouth and that would be very desirable in 
other respects as materials for filling, yet that are 
altogether worthless for this purpose, from lack of 
adaptability. Quartz, if it possessed this property, 
would be valuable as a material ; but as yet there has 
been discovered no method of preparing it in an avail- 
able form. On the other hand, many things possess 
the property of adaptability, that are lacking in some 
other important particulars. 

The next important property is, hardness. A ma- 
terial may possess all the other suitable qualities, and 
yet be too soft. A material should be hard enough 
not to be broken or w T orn away by any pressure or 
friction liable to be applied. This property is espe- 
cially desirable for fillings in the masticatory surfaces 
of the molars and bicuspids. It would, however, be 



MATERIALS FOR FILLING. 79 

admissible to employ a softer material for filling cavi- 
ties in the proximal surfaces of the teeth, provided 
it perfectly excluded all foreign substances. 

Again, a material should be as nearly as possible a 
non-conductor of heat, particularly for filling sensitive 
teeth, or those liable to become so under the influence 
of slight causes. Great variations of temperature will, 
in most instances, aggravate sensitiveness, and, in 
susceptible cases, produce it; and, if the irritation is 
continued, the result may be necrosis. Gold, which 
possesses the largest number of desirable qualities as 
a material for filling, is in this respect very defective, 
being one of the best conductors of heat. To obvi- 
ate this defect, some non-conducting material is em- 
ployed between the gold and the sensitive portion of 
the tooth. The nerve is liable to. be affected by sud- 
den and great changes of temperature, transmitted to 
it through a gold plug. 

In the next place, a material should be susceptible 
of being welded, or united into a solid mass. The 
permanency of an operation depends very much upon 
this quality. A filling having the different pieces 
which compose it perfectly united, will be much more 
durable than if effected with a material in which this 
cohesive property is lacking, it can be made with 
greater facility, and will be better and longer retained ; 
and mainly because such a filling cannot be destroyed 



80 GENERAL REMARKS ON FILLING. 

piecemeal. Non-adhesive material is retained by the 
general form of the cavity, which is to be shaped so 
as to bind all the pieces together, and thus hold them 
in place ; but a substance that will weld, requires only 
two or three good retaining points, angles, or pits, 
properly situated, in order to be firmly and perma- 
nently fixed in a cavity of any form. 

Color. — Another desirable property of material for 
filling, is, such a color as shall best harmonize with 
that of the teeth, particularly if they are in front. In 
this respect, all the metals are objectionable ; though 
gold is probably less so than any of the others, the 
objection to this being not so much in its color as in 
its luster ; which objection, however, may be partially 
obviated by the kind of finish given to the work. In 
teeth of certain shades — semitransparent bluish white, 
for instance — gold, for exposed fillings, is very objec- 
tionable ; indeed, in some cases, almost as unsightly 
as the absence of the tooth ; and, in such instances, the 
darker metals would of course appear much worse. 
For such teeth, some mineral substances, having more 
nearly the color of the teeth, would be most desirable. 

Most of the materials employed for filling are metal- 
lic; only a few non-metallic substances have been 
used, and these rather by way of experiment, and for 
temporary purposes, than with any hope of permanent 
results. Of the metals, gold possesses more of the 



MATERIALS FOR FILLING. 81 

indispensable properties than any other; but the fol- 
lowing have been used for filling; lead, tin, silver, 
platinum, gold, and amalgam. In the preparation of the 
latter, gold, silver, platinum, tin, bismuth, antimony, 
cadium, zinc, and mercury, have been employed. 

Lead. — This metal, in the early history of the pro- 
fession, was used to some extent for filling teeth, though 
it possesses but few of the requisites for that purpose. 
The principal quality which recommended it, is its 
adaptability ; but it is quite too soft for permanent 
fillings in the masticating surfaces of the molars. It 
is easily wrought into foil and welded into mass in 
the cavity, but it is rapidly worn down by mastica- 
tion, and its integrity readily impaired by the influ- 
ence of peculiar conditions of the mouth ; much more 
readily, indeed, than that of tin or silver. Acetic and 
other acids act upon it with considerable energy in 
the mouth. By exposure to air and moisture, it is 
soon coated with carbonate or protoxyd of lead ; and 
this change is effected much more readily in the 
mouth. Lead is also objectionable in color — especially 
for fillings in the anterior teeth — it being darker 
than the other metals employed for the purpose. It 
is, however, a less perfect conductor of heat than some 
others that are in far more extensive use. 

Tin. — This metal has been, and is even yet, much 
employed as a material for filling. It is easily 



82 GENERAL REMARKS ON FILLING. 

wrought into foil, and in that condition is readily 
adapted to the purpose, by reason of its softness and 
pliability. Fillings can be made with it in all cases 
in which non-adhesive gold foil can be used, to much 
of which, indeed, it can, by skillful manipulation, be 
made superior in adhesive property. Its quality, 
however, is greatly dependent on the manner of its 
manufacture. It is harder than lead, and in many 
cases hard enough for permanent fillings : we have 
known it retained in crown cavities of the molars, 
effectually preserving the teeth, for fifteen years. In 
favorable conditions of the mouth, it is not materially 
changed, not oxydizing easily, and not readily uniting 
with any substances liable to be brought in contact 
with it. But in an unhealthy mouth, with the secre- 
tions in an abnormal condition, and the teeth neg- 
lected, tin fillings are very rapidly destroyed, chiefly 
by the action of the soluble chlorides. Such a 
change may take place in the mouth, as will in a little 
time destroy tin fillings that had long remained in. 
good preservation ; and hence this material is not en- 
tirely reliable in any case, since such change may at 
any time occur. Some cases seemingly favorable to 
its use, are found, on examination, to be otherwise ; 
and in almost any mouth in which there is a large 
proportion of mucus secreted, it cannot be depended 
upon for permanency. Its color renders it unfit for 



MATERIALS FOR FILLING. 83 

the anterior teeth. It is a less perfect conductor of 
heat than gold ; on which account it is frequently em- 
ployed where the latter metal can not be. It should 
not be used in a tooth in which there is another metal ; 
notwithstanding some economical dentists do some- 
times use it to fill the interior of large cavities, placing 
upon it a covering of gold. This method is objection- 
able in two particulars : first, the tin is softer than 
the gold, and under much pressure yields beneath it, 
so as to destroy the integrity of the filling ; and second, 
when the fluids of the mouth come in contact with 
the two metals, a chemical action is induced, by which 
the tin is rapidly corroded. It is for this reason that no 
two metals should be applied to the same tooth ; as, for 
instance, tin for filling a tooth round which there is 
a gold clasp, or in contact with which is a gold plate. 
Finally, the use of this material should be deter- 
mined not only by all these circumstances, but also 
by the constitutional predisposition of the patient, 
and the character of the teeth, which should be dense 
and well organized, in order to render it at all ad- 
missible. 

Silver. — This metal was formerly in more exten- 
sive use as a material for filling, than it is at present. 
It is not for this purpose superior to tin in any par- 
ticular, except in being somewhat harder; and in 
some particulars it is inferior, being quite as do- 



84 GENERAL REMARKS ON FILLING. 

structible in the mouth ; more easily affected by cer- 
tain agents, such as nitric acid, nascent chlorine, etc. ; 
less pliable and less adaptable ; more difficult to work 
into foil ; not so readily formed into fillings ; and pos- 
sessed of much less cohesiveness, being almost un- 
weldable by the ordinary method of manipulation. 
Silver is a better conductor than tin, and would there- 
fore in some cases be more objectionable. The saliva 
is often in such a condition as to act upon it with 
great energy and rapidity. Its color, too, is objec- 
tionable. With these disadvantages, its use has very 
properly been wholly abandoned. 

Platinum. — This metal has been but little used for 
the purpose of filling ; though it possesses some of 
the requisite qualities in a. very high degree ; as, for 
instance, indestructibility, in which property it is su- 
perior to gold. In other respects, however, it is very 
deficient ; it has not as yet been wrought into any 
form in which it can be welded with facility ; it is 
difficult to work into foil ; and when it is put into this 
form, it possesses a stiffness and harshness that ren- 
der its adaptation and condensation almost impracti- 
cable. It is more on this account, perhaps, than on any 
other, that it has been so little employed for the pur- 
pose of filling. It has also less adhesiveness than 
gold, and much sooner parts with this property. Slight 
crumpling or bending serves to stiffen it so as to de- 



MATERIALS FOR FILLING. 85 

stroy its applicability. Good fillings may be made 
of well prepared platinum sponge, recently annealed. 
It requires skillful manipulation, however; for the 
least moisture destroys its cohesive property entirely. 
It is a good conductor of heat, and on this account 
objectionable. In the respect of color, too, it is undesi- 
rable. Platinum should never be placed in close prox- 
imity to tin fillings, or to gold plate or clasps of low 
carat. It is not now, however, used in filling at all, 
except experimentally. 

Gold. — Of all the metals that have as yet been 
used 'for filling teeth, gold possesses more of the 
requisite properties than any other, except platinum, 
and sufficiently so for all practical purposes. Twenty- 
carat gold is very seldom affected by any agencies 
with which it is brought in contact in the mouth ; 
pure gold never. In the filling of teeth, there are 
two objects to be aimed at : one, a sufficient hardness 
to withstand the wear of mastication ; the other, a 
thorough protection to the cavity against all foreign 
substances. For the attainment of the first of these, 
gold is not all that could be desired ; yet it is, per- 
haps, as efficient in this respect as any other metal 
that can be employed. But the second object, gold 
when well manipulated, accomplishes very effectually ; 
that is, so long as the filling maintains its integrity : 
after it is partially worn out, it thus far fails, of course. 



86 GENERAL REMARKS ON FILLING. 

In adaptability, too, gold is superior to any other 
metal. It can be elaborated into a variety of forms, 
with any of which very good fillings can be made. 
It can be perfectly conformed to any shape of surface, 
however irregular. A tooth that can be filled at all, 
can be filled with gold. This assertion was made a 
number of years ago ; and if it was true then, it is 
much more true now ; for then the adhesive property 
of gold was not employed at all, or even recognized as 
available ; but now, this property has been rendered 
efficient and practicable. Then, our best operators 
did not aim to unite the different portions of gold of 
which the fillings were composed. The idea that such 
consolidation could be effected, seemed never to have 
entered their minds. Indeed, with the instruments 
and the method of manipulation then employed, this 
adhesive property could not have been made available ; 
but as it came to be recognized, the instruments and 
the manipulation were adapted to the purpose. For- 
merly, an ordinary gold plug when removed from a 
cavity, could be readily separated into as many pieces 
as originally composed it ; but now, when adhesive 
gold is skillfully used, the mass composing a filling 
can not be divided into its original parts, but may be 
wrought into plate, wire, or foil. Non-adhesive gold 
— the modification in which, till recently, it was 
always employed — would not weld, even under great 



MATEEIALS FOR FILLING. 87 

pressure ; but, in the mode in which it is now pre- 
pared, it will weld readily and thoroughly. There 
are certain requisites essential to this welding pro- 
perty of gold: if it is in the form of foil, it should not 
present a smooth, planished surface ; it must be an- 
nealed after hammering, in order that its ultimate par- 
ticles may be in the best condition for cohering : it 
must be entirely free from all deposits of foreign sub- 
stances ; and it must be kept from exposure to the 
atmosphere. 

Gold is a good conductor of heat ; and this is the 
chief objection to it as a material for filling. As to 
sensitive teeth, this is a very serious objection, in 
some cases necessitating the employment of non- 
conducting materials with it, and in others preclu- 
ding its use altogether. The color of gold, however, 
is seldom an objection to its use; though it some- 
times renders it unsuitable for fillings in the front 
teeth. But this objection has been already adverted 
to. 

Various preparations of Gold. — And first, of the 
manufacture of gold foil. For this purpose, pure 
gold is used; for procuring which, various methods 
are employed. But the most common of these are 
insufficient for the production of gold absolutely pure. 
It is, however, deemed irrelevant here to detail the 
process by which this end is attained : it is enough to 



85 GENERAL REMARKS ON FILLING. 

premise that, for the manufacture of the best quality 
of foil, perfectly pure gold is indispensable. The 
gold is cast into an ingot about an inch wide, which 
is placed between a pair of rollers, and rolled down 
as thin as practicable, the piece, while rolling, being 
frequently annealed. It is then cut into squares, 
which are inserted with wooden pliers between vel- 
lum leaves, a hundred and sixty or seventy in a 
pack. Over this pack two pockets are drawn, in- 
closing it completely. The pack then is hammered 
on a marble block, with a hammer weighing twelve 
or sixteen pounds, till the leaves are spread out to 
the full extent of the pack. Much experience and 
skill are requisite to the proper accomplishment of 
this part of the work : by a single unskillful stroke of 
the hammer, a whole pack might be spoiled. 

Gold foil is numbered according to the grains con- 
tained in each leaf, ranging from 2 to 30. The most 
common numbers are, 2, 3, 4, 5, 6, 8, 10, 15, 20, and 
30, the smaller, from 2 to 6, being in most frequent 
use. It has heretofore been a desideratum to obtain 
gold foil perfectly uniform; but some few manufac- 
turers now seem to have attained this perfection. 

Crystal Gold. — This form of gold was introduced to 
the profession about fourteen years ago. Some ex- 
periments in this direction, indeed, had been made as 
early as 1825, by C. Ash, of London, and again in 



MATERIALS FOR FILLING. 89 

1850, by Dr. S. A. Main, of New York. Their prep- 
arations, however, were simply precipitates, and 
nothing more. But in 1853, Dr. A. J. Watts, of 
Utica, New York, obtained letters patent for his prep- 
aration of gold for filling teeth. This preparation 
was at first denominated sponge gold, but after some 
modification, received its present name. There are 
numerous formulas by which preparations of crystal 
gold may be made ; but so far as we are acquainted 
with them, they are all embraced in two general 
methods : the one, to obtain simply a precipitate of 
the metal, adaptable to the filling of teeth ; and the 
other, to combine this precipitate with mercury, 
and obtain a definite crystallization. For the prepa- 
ration of the sponge or crystal gold, the absolutely 
pure metal is required. This is dissolved in nitro- 
muriatic acid, the gold being added till the solution 
is saturated. Various materials may be used to pre- 
cipitate it, the most common of which are sulphate of 
iron and oxalic acid, the latter on some accounts 
being preferable. The character of the precipitate 
will be determined, in a great degree, by the manner 
in which the precipitant is added : if slowly, the pre- 
cipitate will be more fibrous, or structural. 

A preparation may be made by introducing the 
precipitant gradually, and then carefully washing the 
precipitate, and heating almost to redness. For per- 



90 GENERAL REMARKS ON FILLING. 

feet crystallization of the gold, combine the precipi- 
tate with from six to twelve times its weight of pure 
mercury, let it stand a short time, subject to a gentle 
heat, and then remove the mercury with dilute nitric 
acid. Afterward wash the nitrate of mercury from 
the gold ; place the latter upon a slide, and bring it up 
to a full red heat in a muffle, and the gold is then in 
a condition to be used for filling. This is about the 
formula on which a patent was granted to A. J. 
Watts. The preparation possesses some advantages 
over gold foil : it is as readily introduced ; it is more 
capable of thorough consolidation ; it has, besides the 
cohesiveness of foil, the additional property of inter- 
lacing its crystals one with another, by which prop- 
erty, even without cohesion, the pieces of a filling 
can be firmly united ; and it takes a better hold upon 
the walls of the cavity, to which it presents the 
angles and ends of the crystals, so as to be more 
thoroughly adapted and fastened. 

Amalgam. — By this term are designated all those 
preparations formed by a combination of mercury 
with various other metals ; most frequently with sil- 
ver and tin, but occasionally with gold, platinum, 
bismuth, cadmium, zinc, and lead. The several form- 
ulas for amalgam need not here be specified. The 
kind most in use is prepared by melting together and 
carefully mixing pure tin and silver, filing this mix- 



materials for filling. 91 

ture, when cooled, into dust, combining the latter 
with mercury in sufficient proportion to give the 
requisite plasticity, and then thoroughly washing the 
whole in alcohol or boiling water, to remove the 
oxyds formed during the combination of the metals. 
If there is a redundance of mercury, it may be re- 
moved by pressing the paste in a piece of chamois skin. 
This preparation may in some cases be used for 
filling with considerable success ; but in no case can 
it be relied upon as a durable material, its destructi- 
bility being no less than that of tin or silver in any 
circumstances, and being greater where all the mer- 
cury is not removed from the surface of the filling, 
and the surface not burnished down solid and 
smooth. Mercury oxydates with considerable rapid- 
ity when exposed to air and moisture, and with 
increased energy, under the influence of heat, especially 
when some acid is present. This facility of oxyda- 
tion is still increased when other metals are com- 
bined with mercury. Oxydation of such fillings will 
in some cases be confined to the surface, wherever 
there is contact of moisture ; in others, it will per- 
vade the whole mass, rendering it black and spongy 
throughout. 

Amalgam fillings, in a short time after their inser- 
tion, undergo a hardening process, occasioned by crys- 
tallization of the mass, as well as by evaporation of the 



92 GENERAL REMARKS ON FILLING. 

mercury. The consequence is, either that the mass 
becomes porous, or that it contracts ; the former, 
doubtless, in cases where the oxydation blackens 
through, and the latter, where it is confined to the 
surface. When a plug is in either of these conditions, 
the preservation of the tooth is very uncertain. On 
removing an ordinary amalgam plug that has been worn 
for some time, its entire surface will generally be found 
oxydized : and a tooth filled with this material gene- 
rally becomes blackened, and its appearance ruined. 

To such objections against this material, another is 
to be added in cases in which there are fillings or plate 
of platinum or gold : galvanic action will be estab- 
lished, in a degree proportionate to the proximity and 
extent of surface of the metals and the condition of 
the secretions. This may occasion much mischief. 
Some constitutions are very susceptible of the influ- 
ence of mercury ; and a gradual decomposition of sev- 
eral amalgam fillings in the mouth, may seriously 
impair the general health. Therefore, before this 
material is ever employed, the health, temperament 
and habits of the patient, should be carefully noted ; 
for these and other circumstances may often indicate 
its inadmissibility. 

So great and so numerous are the objections to this 
material, that it is but little used by reliable opera- 
tors. Its adaptability is the main property on which 



MATERIALS FOR FILLING. 93 

are based the arguments in its favor : it is easily ap- 
plied, and consolidates with considerable hardness. 
It is affirmed, also, that teeth which can not be saved 
with any thing else, may be filled with this, and made 
valuable. This, however, is not true since the em- 
ployment of the adhesive property of gold ; which 
property renders this metal equal in adaptability to 
amalgam. 

Non-metallic Materials. — Of the non-metallic mate- 
rials experimented with for filling, there are not many 
worthy of any particular consideration. Indeed, gutta- 
percha and its preparations constitute the chief of 
these substances now used for this purpose, though 
some others have been employed. Gutta-percha is 
useful for temporary fillings, and, under ordinary cir- 
cumstances, is sufficiently durable. It is valuable for 
filling those teeth which it may be desirable to retain 
only a short time, or those in which it may be neces- 
sary temporarily to protect a sensitive part against the 
influence of irritating agents, in order to restore it to 
health. Gutta-percha is not readily decomposed by 
the fluids of the mouth, when they are in a healthy 
condition. In some instances we have known it worn 
in the mouth for years, with but little change. But 
in cavities on the grinding surfaces of the molars and 
bicuspids, it will not withstand the wear of mastica- 
tion a great while, though long enough in most cases 



94 GENERAL REMARKS ON FILLING. 

to subserve the purposes of temporary fillings. It 
possesses great adaptability : by simply being warmed 
over a spirit-lamp or in boiling water, it becomes plas- 
tic, and is with great facility introduced and con- 
formed to the cavity. It may be applied also in solu- 
tion, being dissolved in chloroform till it approaches a 
pasty consistence, then absorbed in a pledget of cotton, 
and introduced into the cavity ; where the chloroform, 
evaporating, leaves the gutta-percha as a filling. The 
only objection to this method is, the contraction con- 
sequent on the evaporation of the chloroform. Another 
property that renders this substance highly valuable, 
is, its non-conduction of heat, it being in this respect 
as nearly perfect as any other material employed. 

A preparation of gutta-percha with mineral sub- 
stances, known as Hill's stopping, has for some years, 
been extensively used for temporary fillings ; indeed, 
it has superseded simple gutta-percha almost entirely. 
The aim of this preparation was to obviate two or 
three objections to pure gutta-percha; as, its contrac- 
tibility in the cavity, its softness, and its color. The 
composition of Rill's stopping is as follows : With pure 
gutta-percha in a plastic state, are mixed quicklime 
two parts, and quartz and feldspar one part each, 
which latter are reduced to an impalpable powder, and 
kneaded into the mass as long as it will receive them 
without becoming brittle. Such is the formula given 



MATERIALS FOR FILLING. 95 

by the inventor of this preparation ; though it is pre- 
sumed that one of these materials alone, namely, pul- 
verized quartz, would be found entirely sufficient, 
since it is capable, by itself, of quite as much as is 
attained by all together. The addition of gold or 
platinum filings has been recommended ; but no 
advantage is thus gained. It was at first claimed for 
this material that it would serve for permanent fill- 
ings ; but it was soon demonstrated to be insufficient. 
It was supposed, also, that it might be employed for 
partial fillings in large cavities, which could be com- 
pleted with gold; but for this, too, it was found 
impracticable, since it did not make a sufficiently firm 
foundation. 

This preparation is applied in the same manner as 
simple gutta-percha, being warmed on a porcelain or 
metal slab over a spirit-lamp till sufficiently soft, and 
then packed into the cavity. It cannot be employed 
in the form of solution, nor should it be softened in 
boiling water. It may be conveniently prepared by 
dissolving the gutta-percha in chloroform to almost 
a pasty consistence, then adding the mineral sub- 
stances, and putting it into a vessel suitable for the 
evaporation of the chloroform. It should be made so 
thick, that the silex would not fall to the bottom. 
When Hill's stopping or gutta-percha is used, as soon 
as the cavity is filled, an instrument with the end 



96 GENERAL REMARKS ON FILLING. 

nearly as large as the orifice of the cavity, should be 
placed upon the filling, and retained there with con- 
siderable pressure till the mass is cool. After cutting 
and dressing the surface of the filling as perfectly as 
can be with instruments, then by passing over the 
surface a short camel's-hair brush, with chloroform, a 
very smooth surface and perfect finish will be made. 
In some respects, there is, perhaps, nothing better 
for temporary fillings than this preparation of gutta- 
percha. 

Os Artificial. — This preparation is an oxy-chloride 
of zinc, and has been used for several years for filling 
teeth ; and when well prepared, and properly manip- 
ulated, serves a very valuable purpose. In very many 
cases it resists the secretions of the mouth quite effectu- 
ally. For proximal fillings it resists the wear of masti- 
cation well, but for crown fillings it is not sufficiently 
resistant. It is one of the best materials for temporary 
filling. A little experience renders its use easy. It 
effectually excludes all foreign substances; is a good 
non-conductor ; and is only displaced by wear. It is 
a good protection to sensitive dentine, and in many 
cases for exposed pulp, under gold filling. It more 
nearly resembles the natural teeth in color than any 
other material that has been used for filling. To Dr. 
C. H. Roberts is due the credit of having brought this 
material to its present state of perfection. 



CHAPTER IV. 

INSTRUMENTS FOR FILLING. 

In describing the instruments for filling teeth, it 
will be convenient to take them somewhat in the 
order in which they are employed in ordinary prac- 
tice ; first referring to those which are used for cut- 
ting away portions of the teeth, for the purpose of 
separating them, and for dressing off the borders of 
cavities ; then to those for removing decay and form- 
ing the cavities ; and finally to those for introducing, 
consolidating, and finishing fillings. The first, then, 
that claim our attention, are the 

HEAVY CUTTING-INSTRUMENTS. 

These are of the thick chisel shape. They should 
be of good steel, well wrought, and thoroughly tem- 
pered. Every step in the process of their manufac- 
ture should be most perfectly executed, so as to in- 
sure an edge that will cut not only dentine, but also 
enamel, which is the hardest animal substance. Va- 
rious sizes of the straight chisel form are required. 



98 



INSTRUMENTS FOR FILLING. 



In all cases they should be as thick as possible, with- 
out being thus impaired in their efficiency ; so firm 
that there may be no springing or tremulous motion 
under the pressure they are required to sustain. For 
separating front teeth, however, they must be thin 
enough to pass readily into the intended space, and 

Fig. 3. 



about one-fourth of an inch wide at the edge. But, 
for separating bicuspids and molars the instruments 
should be thicker and broader • as thick, indeed, 

Fig. 4. 




as the required space will admit. In some cases, 
they should have the edge oblique, as in Fig. 5. 
It is seldom that these instruments need any curve. 

Fig. 5. 




The straight form is the best, unless, as it rarely hap- 
pens, the point to be operated upon cannot be reached 
efficiently with it; as, for instance, in a small mouth, 
a slight anterior curve will be required in the shaft 



DRILLS. 



99 



of the instrument, to facilitate its approach to the 
front proximal surface of a second or a third molar. 
(Fig. 6.) A heavy instrument, with a sharp point 



Fig. 




and a lateral curve, is often efficient in opening up 
cavities and cutting down strong projections of ena- 
mel. (Fig. 7.) We consider as a very valuable 

rig. 7. 




form. Every operator should have at hand a suffi- 
cient variety to meet every demand — from three to 
five sizes of each form. 

DRILLS. 

Bur Drills. — Of this indispensable class of instru- 
ments there are various forms. They should be man- 
ufactured of the best steel, and wrought with the 
greatest care. After having been forged as near the 
proper size as possible, the bulb is shaped by dressing 
with a fine file, or which is better, by turning in a 
lathe ; those made by the latter method being supe- 
rior, and cutting much more smoothly ; they do not 
catch and jar as do those of less regular form. After 



100 



INSTRUMENTS FOE FILLING. 



the bulb is formed, it is usually cut with a sharp- 
edged file. 



Fig. 8. 



Of these drills, Fig. 8 represents a bur of a spher- 
ical form. Fig. 9 is cone-shaped, which may have 

Fig. 9. 



various degrees of bevel, terminating in a sharp point. 
Fig. 10 is of a cylindrical form, cut upon the sides 
and end. Fig. 11. is in the form of a wheel, cut upon 

Fig. 10. 




the edge only, or upon both the edge and the end. 
The cutting upon all of these should be very regular 
and uniform. This should be made by machinery, 
though it is usually done by hand. Of these instru- 

Fig. 11. 




ments, there should be a variety in size, the smallest 



DRILLS. 101 

considerably less than the smallest cavity the dentist 
ever attempts to fill — that is about one thirty-second 
of an inch in diameter, and the largest about one-fifth 
of an inch. Inclusive of these extremes, there should 
be about ten sizes of each particular form. These 
instruments are used for opening cavities. With them 
a more regular and perfect orifice is made in small 
and medium-sized cavities, than by any other method. 
They are also used to some extent for forming the 
cavities, and even sometimes, in large cavities, for 
making retaining-points for a filling. 

Within comparatively a recent period a new form 
of drill has been introduced by Dr. Scranton ; and 
hence denominated u Scranton s Drill." 

Its form is spherical, and in the manufacture the 
bulb is formed as for the ordinary bur drill ; but in- 
stead of having cut upon it numerous serrations, thus 
forming a series of sharp edges : a cutting is made 
upon two opposite sides with a small round file. The 
instrument then presents two concave and two convex 
sides, with four sharp longitudinal edges ; these may 
be so inclined as to cut, only when rotated in one 
direction ; or to operate alike well when rotated either 
to the right or the left. 

This instrument has two or three advantages over 
the ordinary bur ; it can be kept sharp with the oil 
stone till it is almost entirely used up ; and will con- 



102 



INSTRUMENTS FOR FILLING. 



sequently last much longer ; and it will cut much 
more rapidly than the serrated bur. It is a very 
valuable instrument for operating upon firm strong 
teeth. It is represented in Fig. 12. 

Fie. 12. 



Common Drills. — Of other drills, Fig. 13, repre- 
sents one with a square point, beveled from both 

Fie. 13. 



sides, measuring from a half to a whole line in length, 
and attached to a small round shaft. The edges of 
the drills should be very hard, so that they may cut 
with the greatest celerity. Of this kind, there should 
be about ten sizes, ranging in width from No. 12 to 
No. 25 of Stubb's gauge. These are used mainly for 
forming retaining-points in cavities. 

Fig. 14. 




Fig. 14 is the spear-shaped drill, the edges of which 
are formed by dressing from both sides ; or, it may be, 
from only one, in which case it will cut only when 



DRILLS. 103 

rotating one way. This shape is employed principally 
for drilling out fangs for filling, or receiving pivot teeth. 
The burs and drills may be made of pieces of wire 
one and a half inches long, and fitted to a socket- 
handle that will accommodate a large number ; or of a 
continuous piece of large wire. The latter is the pre 
ferable method, since much time is consumed in chang- 
ing them in sockets. The handles should be made 
with six or eight sides, and cut on each alternate side. 
In the use of these instruments, the drill-ring is al- 
most indispensable. This is an open ring for the 
middle or the index finger, with a socket attached, 
in which rests the end of the handle of the instru- 
ment. (Fig. 15.) The drill is rotated commonly 
with the thumb and fingers. 

Fig. 15. 




Brill-stocks of various forms have been invented 
with the view of increasing the motion of the drill 



104 



INSTRUMENTS FOR FILLING. 



of augmenting its power, or, especially, of bringing it 
to bear upon points inaccessible to the straight in- 
strument. Some of these stocks are very compli- 
cated ; as, for example, that denominated Chevaliers 

Fig. 16. 




drill-stock, than which there are none better adapted 
for bringing the drill to bear in various directions. 
(Fig. 16.) Another, more simple in construction, 
called Merry s drill-stock, was some years ago intro- 
duced to the notice of the profession. With this, 
the drill can be applied at any desired angle, the 
operator having almost as complete control of the in- 
strument as of the common straight drill. (Fig. 17.) 

Fig. 17. 




Broaches. — The broaches of three or four sides are 
made of the best steel, and are of various sizes.- 
They are constructed both of a straight and of a ta- 
pered form. They should in no case have more than 



EXCAVATORS. 105 

a spring temper, in which the color, when drawn, 
is a deep blue. These instruments are used for en- 
larging the canals of fangs for the purpose of filling. 
Six or eight sizes will probably meet all ordinary 
cases. When the course into the canal is tortuous, 
the temper of the instrument should be so low as to 
spring readily. 

EXCAVATORS. 

Of the small cutting-instruments for opening and 
forming cavities and removing decay from them, there 
is a great variety, though a few general forms com- 
prise the whole. Hitherto there has been no very 
systematic arrangement of these instruments, such as 
the convenience both of the profession and the man- 
ufacturers of dental instruments would seem to dic- 
tate, In a classification that we have adopted and 
found very convenient, they are arranged by num- 
bers, the most simple being placed under the first, and 
under each successive number a more complicated 
form. All the varieties are embraced in twelve 
numbers, which are represented in Figs. 18 and 19. 
These varieties are discriminated by the forms of the 
points and their position on the shaft to which they 
are attached, and not by any curve which the shaft 
may have at any distance from the point. 



106 



INSTRUMENTS FOR FILLING. 
Fig. 18. 




No. 1 has simply a flat point slightly curved, with 
a round edge transverse to the shaft. Four sizes will 
be sufficient for ordinary purposes. 

No. 2 has a flat point with a short curve, bringing 
the point to a right angle with the shaft ; the edge is 
transverse. This differs from No. 1 in having the 
curve more short and abrupt, and the edge more 
nearly square. Of these there should be five sizes, 
with some variety of form. 

No. 3 has a flat point with a square transverse 
edge, which rises at a right angle from the shaft ; the 
blade being from one to two lines in length. Five sizes. 

No. 4 has a flat point, curved so as to be at a right 
angle with the shaft ; the blade, from the center of 



EXCAVATORS. 107 

the curve to the edge, being from one and a half to 
three lines, and the edge straight. Four sizes. 

In each of the foregoing the edges should expand 
slightly in width. 

No. 5 has a flat point with a square edge, which is 
parallel with the shaft, and rises at a right angle from 
it. The blade is from one-half to two and a half lines 
in length, and from one-half to one line in width, with 
no expansion at the edge. Six sizes, with some vari- 
ety of form. 

Nos. 6 and 7 are right and left excavators, with 
flat points and double curves ; the first curve being 
at an angle of about twenty degrees, and the other 
lateral, right and left, reaching from the beginning of 
the first curve to the point. The length of blade is 
from one to four lines. Four sizes. 

No. 8 has a crescent-shaped point, the blade rising 
by a small attachment from the shaft, and making a 
right angle with it. The edge is a regular curve, de- 
scribing about two-fifths of a circle, and is parallel 
with the handle. The point should be perfectly 
formed. Six sizes. 

No. 9. The form of the point is the same as in No. 
8, the difference being in the position of the blade. 
the edge of which is transverse to the shaft, and rises 
from it at an angle of one hundred and thirty degrees. 
Six sizes. 



108 INSTRUMENTS FOR FILLING. 

In No. 10 the point has the same shape as .in Nos. 
8 and 9. The cutting edge is transverse to the shaft, 
and rises by a small neck at a right angle from it. 
Six sizes. 

Such are the most important forms of excavators ; 
though modifications will be required for particular 
cases. While Nos. 8, 9, and 10 are not in extensive 
use, a few operators have used them for some years, 
and prize them very highly. In many difficult cases 
they are far more applicable than any other instru- 
ment we have. For instance, in the formation of the 
cervical wall of a proximal cavity in any of the teeth, 
but particularly in the superior bicuspids and molars, 
there is no other instrument so applicable and efficient 
as No. 9 : with it, that part of the cavity, so fre- 
quently neglected, is just as easily formed as any 
other. 

Cases will occasionally be presented, in which some 
curvature of the shaft of the instrument will be requi- 
site. But no more curve should be given to any in- 
strument than may be absolutely necessary, for it is 
impossible to manipulate with the same precision and 
delicacy with curved as with straight instruments. 
The degree of curve necessary in any given case will 
be determined by the position of the decay on the 
tooth, and the location of the latter in the mouth. 

Since the first edition of this work was written, 



EXCAVATORS. 



109 



some variations have been made from these forms ; 
embracing, however, the general principles. For in- 
stance, the diamond point, as it is familiarly, called, is 
a modification of No. 3 in Fig. 18, varying from it in 
that it has a sharp point instead of a square edge, and 
is three-sided from shaft to point, each angle being a 
cutting edge. This instrument is especially valuable 
for forming grooves or furrows within cavities, and for 
dressing the borders. 

Fig. 19. 



11 



r^ 



12 



After being much reduced by use, it may still be 
kept in form, and sharp, and used as a drill for making 
under-cuttings, for which it is very efficient. No. 11 
(Fig. 19) represents this instrument. 

A modification of No. 9, (Fig. 18), commonly known 
as the scoop or spoon-shaped instrument, is exten- 
sively used. The sharp corners of No. 9 are removed 
in this instrument. It is shown in No. 12, (Fig. 19.) 

Of the Manufacture of Excavators.— For making 
these instruments, the best cast-steel wire, No. 8. 
should be selected. This should be forged down 
so as to leave the end large enough to form the 



110 INSTRUMENTS FOR FILLING. 

intended point. Nos. 1 to 6 inclusive, may be formed 
by forging, and afterward dressing up with the file. 
Nos. 7 to 12 must be formed by the files out of a 
bulb left from the forge ; for which purpose different 
forms and sizes of files will be required, in order 
definitely to shape all the angles and points. In heat- 
ing steel, either for forging or tempering, a full red 
heat should in no case be exceeded, since a higher de- 
gree than this spoils it. After the points are formed, 
and made smooth with an emery stick or wheel, they 
are to be tempered ; which is a delicate process, re- 
quiring much experience and care. The point should 
be warmed in a spirit-lamp, and then covered with 
soap, to prevent o'xydation and scaling. The instru- 
ment is then brought up to a full red heat with a 
spirit-lamp, blow-pipe, and charcoal, and suddenly 
plunged into a cake of soap or into cold water ; when 
it will present a silvery whiteness : the steel in this 
condition is extremely hard and friable, it then 
should be polished off with an emery stick or oil- 
stone, and drawn down to the proper temper. This 
tempering is accomplished by placing the edge of the 
instrument on a piece of cold polished steel or iron, 
and its shaft placed near or in the flame of a small 
spirit-lamp, and retaining it there till it changes to a 
deep blue color, graduated down to the point in a deep 
straw or copper hue. The purpose in holding the 



PLUGGING INSTRUMENTS. Ill 

point of the instrument on a piece of cold polished 
iron or steel is, that the heat there may be subject to 
complete control. The precise shade will be governed 
by the purpose for which the instrument is to be used ; 
if for a drill, the edge or point should be of a light 
straw color ; indeed, some operators prefer to have 
them scarcely changed at the cutting edge, while ex- 
cavators and chisels should be brought to a deep straw 
or copper color ; this will be modified, however, by 
the manner of working the steel, and its quality. 
Skillfully hammering steel at a low heat — below a 
red — adds much to its quality for a fine cutting instru- 
ment, and gives an improved texture. Indeed, some 
assert that those instruments that can be forged to 
nearly their proper shape, can be as well, if not better, 
tempered by the hammer as by any other means. 

The instrument is then to be polished by the emery 
wheel and dressed up with the oil-stone. Of the va- 
rious methods of tempering, the foregoing is equal in 
efficiency, and in convenience superior, to any other. 

PLUGGING INSTRUMENTS. 

For introducing and consolidating fillings, a great 
variety of instruments is in use. In filling with gold 
in some of the forms in which it is employed, the 
plugging-pliers are required, for picking up the pieces 
of gold and placing them in the proper positions in 



112 INSTRUMENTS FOE, FILLING. 

the cavity ; in cylinder or block-filling they are indis- 
pensable. These instruments are made of different 
forms and sizes — of different forms, to facilitate 
access to cavities inconveniently located ; of different 
sizes, to accommodate cavities of various capacities. 
For a large majority of cases, they require a slight 
curve, about half an inch from the point ; for some 
cases, however, the curve should be a right-angle. 
(Fig. 20.) 

Fie. 20. 



The points of the pliers, when shut together, should 
form the point of a plugging instrument, so that it 
may be used to some extent for consolidating the 
gold. This instrument should be about five inches 
long. 

The forms of condensing instruments may be mul- 
tiplied to an almost indefinite extent. They are all, 
however, but modifications of two or three general 
principles. The particular form of the plugging point 
will be determined by the form in which the gold is 
used. With non-aclhesive gold, small square, round, 
sharp points, of various curves, will be required. 
(Fig. 29.) These points are easily kept in proper 
condition, and, in some instances, are used for years 
without any change or repair. 



PLUGGING INSTRUMENTS. 



113 



A favorite method of filling with non-adhesive 
gold, by many excellent operators, is in the use of 
cylinders or blocks; for this method, instruments 
especially adapted have been devised, which the 
following cuts represent. 

Fig. 21, represents the lateral condensing instru- 
ments, used for consolidating the cylinders upon each 
other as they are introduced. 

Fig. 21. 




Fig. 22, is square from the curve to the point, and 

Fig. 22. 




is used in the same manner, and for nearly the same 
purpose as Fig. 21. 



114 



INSTRUMENTS FOR FILLING. 



For introducing and condensing key-blocks — those 
intended to bind the filling in place— Fig. 23 is the 
proper form. 



Fis. 23. 




Figs. 24 and 25, are designed for condensing the 
surface of crown fillings, in the superior and inferior 
molars respectively. 

Fig. 24. 




Fis. 25. 




The instruments represented by the following, are 
for condensing the surfaces of proximal fillings. 

Fig. 26. 



PLUGGING INSTRUMENTS. 



115 



Fig. 27, represents round right and left condensing 
points, to be used in filling proximal cavities. 

Fig. 27. 




Fig. 28, flat right and left condensing points, for 
same cavities as Fig. 27. 

Fig. 28. 




With adhesive gold in any of its forms, the points 
all require to be serrated. There are three or four 
varieties of these, which it will be proper to describe. 
The first is square, and slightly bent about half an 
inch from the end, which is formed into four or six 
definite sharp points with the ei]ge of a thin file. Of 



116 



INSTRUMENTS FOR FILLING. 



this variety there should be about five sizes, the 
largest entering No. 18 of Stub's gauge, and the 

Fig. 29. 




smallest No. 25. The former should have six points, 
and the other two sizes four. (Fig. 30.) The cuts 

Fig. 30. 




upon these are made directly across the end. In 
another variety, the end is rounded, and the file 
placed upon it at an acute angle with the side of the 
instrument, and the cuts, three in number, are made 
to the centre of the point, which thus becomes 

Fig. 31. 




^ 



triangular, or three-pointed, from a common center. 
(Fig. 31.) Four or five sizes of these may be 



PLUGGING INSTRUMENTS. 



117 



employed, ranging from 18 to 26, Stub's gauge. A 
thin double point, from 26 to 28, is in many cases 
very valuable. Instruments with a condensing sur- 
face on the side, instead of the end, will frequently 
be required for filling lateral cavities ; these may be 
denominated lateral pluggers. (Fig. 32.) This COn- 
Fig. 32. 




densing surface should also be serrated, as already 
described. An instrument square at the point, 
ranging from 18 to 22, and cut upon the end by 
passing it along the cuts of a file both ways, thus 
making a large number of small serrations at right 
angles across the point, is valuable for consolidating 

Fig. 33. 




the surface of a plug. (Fig. 33.) Operating super- 
ficially, on the principle of the more deeply serrated 
instruments, it yet leaves the surface free from deep 



118 INSTRUMENTS FOR FILLING. 

pits or indentations, and still so impressed that it 
will receive and retain more gold, if necessary, as it 
would not clo, if the end of the instrument were per- 
fectly smooth. A smooth-pointed instrument or bur- 
nisher may be applied after all the gold has been added. 

Fig. 34. 



Fig. 34 is an instrument with file-cut sides. It is 
valuable for dressing down proximate fillings to a 
uniform surface. There may be two, one with the 
sides parallel with the shaft, and one with its sides 
transverse to the shaft ; it terminates in a sharp edge. 

In many cases a valuable instrument for consoli- 
dating is the plugging forceps, the general form of 
which, except the beaks, is that of the ordinary 
straight extracting forceps. The beaks are formed 
into sockets for the reception of the plugging points, 
one of which is of the common construction, but the 

Fig. 35. 



other has a broad flat surface, to rest against the 
tooth. (Fig. 35.) This instrument is applicable only 



THE FILE. 119 

in certain cases, principally in filling proximal cavi- 
ties. Its main advantage consists in its capability of 
applying a strong pressure upon the filling, without 
affecting the socket. Manipulation with it is less 
rapid and definite than with the ordinary condensing 
instruments ; and with it, too, there is much danger 
of fracturing friable teeth. 

There has been within the last few years, very 
great improvement made in the serrated plugging 
instruments — those employed for working adhesive 
foil. It consists in delicacy and perfection of form, 
a large addition to the variety, and a good systematic 
arrangement. 

These instruments are now manufactured and put 
up in sets, embracing every requisite form, number- 
ing from forty to sixty ; this includes surface con- 
densers and burnishers. 

The profession is largely indebted to the efforts of 
Drs. W. H. Atkinson and F. Abbott, of New York, 
for the perfection obtained in the production of these 
instruments. 



THE FILE. 

Of this valuable .and indispensable instrument 
there is a variety of forms used by the dentist. The 
thin files (Fig. 36) are chiefly applicable to the ante- 



120 



INSTRUMENTS FOR FILLING. 



rior; the thick, heavy, knife-shaped (Fig. 37), to the 
posterior teeth. The latter, to facilitate their ap- 
proach to the points operated upon, have various 
curves, some single, others double ; the double being 
preferable, since they bring the handle of the instru- 

Fig. 36. 




ment on a line with its cutting edge. The cuts upon 
this instrument, too, are quite various; in size 



Fig. 37. 



%MME 



lllllillllllillillllilllliliiiiiiiiiiiiiiiifill iiiiliiiiliiiiiiiiiiilliliilllillllllllilillllliP 




ranging from very coarse to very fine, and in obli- 
quity from a line almost at right angles across it, to 
one at an angle of forty-five degrees. These cuts, 
too, are either single or double, the double being 
those made across one another. The single, however, 



THE FILE. 



121 



are preferable for all operations on the teeth; and 
the more oblique are to be recommended, since they 
cause less of that jarring unpleasant sensation to the 
patient. 

There are in use various forms of file-carriers, two 
of which are represented in Figs. 38 and 39. Fig. 

Fig. 38. 




Fig. 39. 




39, denominated " Redman's file-carrier," is the best 
form yet introduced ; one principal advantage of this 
instrument, consists in the facility with which it may 
be changed from the one side to the other. Files 
are made adapted to the instrument. The chief 
advantage of which is, that they retain the file much 
more firmly than it can be held in the fingers. 



122 INSTRUMENTS FOR FILLING. 

These carriers are made with a variety of curves, to 
accommodate different positions. There is also a 
great variety of small file-point instruments for dress- 
ing down fillings, the more important of which are 
represented in Fig. 40. 

Fig. 40. 




The Use of the File. — When a separation of the 
teeth is requisite, preparatory to filling, it is accom- 
plished, either in whole or in part, with the file. 
Principally, in such a case, its use is restricted to 
finishing and smoothing, after the greater portion of 
the work has been done with the heavy cutting 
instrument. The file is valuable for removing super- 
ficial decay, being called into frequent requisition in 
caries of this kind. It is employed to dress off fangs 
preparatory to the insertion of pivot teeth ; for which 
purpose it is required to be of a round or half-round 
form. It is used for dressing off sharp portions or 
edges of the teeth, that may be injurious to the soft 
parts, and in some cases for dressing down a tooth 
that is elongated. In finishing fillings it is indispens- 
able. It was formerly used to some extent in the 



THE FILE. 123 

treatment of irregularity; but for this purpose it is 
now, or should be, abandoned. 

Mode of Using the File. — The patient should be 
conveniently seated, with the head on a firm support, 
and under the control of the operator, who should 
occupy a position at the right of the patient in most 
cases, so disposing the head of the latter as to give 
the free access to that point which is to be operated 
upon. In manipulating with the file, considerable 
skill and delicacy are requisite. It should not be 
held with a stiff, unyielding grasp, so as to catch and 
jar, but should be applied with a gentle pressure, and 
drawn across the tooth with a free and flexible 
motion. It should be frequently moistened, and not 
allowed to clog with the filings, being kept free of 
these by constant applications of the brush. A 
sharp, new file, with a quick, light movement, will 
cut far more rapidly, and less unpleasantly to the 
patient, than one that is dull or clogged, applied 
with a heavy pressure. If the tooth bone is sensi- 
tive, the file should be moistened in warm water. 
When a file has become clogged with the dentine, it 
may be perfectly cleaned by immersing it a few 
hours in dilute hydrochloric acid, and then washing, 
boiling, and finishing with oil. The form of a file 
may be changed by drawing the temper, bending it 
as desired, and then re-tempering it. It is better. 



124 INSTRUMENTS FOR FILLING. 

however, to have them made of the proper form at 
first. 

The teeth, while being filed, should be supported 
by the fingers, or by an instrument for the purpose ; 
or a cork or piece of soft wood may be inserted 
between the tooth being filed and the teeth of the 
opposing jaw, and the pressure thus used as a sup- 
port. The tooth being sustained in this manner, 
there is less jarring experienced by the patient, and 
less liability to produce irritation of the periosteum. 
When riling the anterior teeth, it is generally better 
to hold the file in the fingers. For filing the incisors 
and canines, a thin, bevel-edged file is to be pre- 
ferred. In dressing a tooth with a file, the last that 
is used should be a fine one ; after the application of 
which, the surface operated upon should be made as 
smooth as possible with a stone and burnisher, or 
with a buff charged with rotten-stone. 

In separating teeth with the file, where but one is 
decayed, care should be taken not to cut the sound 
one. For this purpose, it will usually be necessary 
to have a safe sided file — one side smooth to present 
to the sound tooth ; and even then the cutting edge 
should be somewhat beveled from the safe side, that 
the sharp angle of that edge may not rasp the sound 
tooth ; in no case of this kind should a square-edged 
file be used. In cases in which it is necessary to 



THE FILE. 125 

file teeth that are somewhat loose in the sockets, and 
whose periosteum is in a state of irritation, to build 
up a wall of plaster of Paris round them, permitting 
it to harden, will v.ery much facilitate the operation. 
Perhaps a preferable method in some respects, for 
accomplishing the same object, is to mould softened 
gutta-percha to the tooth and the parts about it. 
After it has become hard, hold it firmly in place 
while the filing is accomplished. Either of these 
methods will be found valuable in cases where it is 
necessary to dress off a considerable portion from the 
end of one or more inferior front teeth. There are 
some teeth upon which the use of the file is hardly 
admissible ; as, for instance, those which are highly 
predisposed to inflammation and sensitiveness of the 
dentine. The teeth of young persons being usually 
of this character, they should be filed with great 
caution; but, in general, those of adults may be 
filed, if properly, with more freedom. The file 
should not be used upon the teeth, when the perios- 
teum, the gums, or the mucous membrane is dis- 
eased, or strongly predisposed to such a condition. 
It should never be used for the correction of irre- 
gularity of the teeth, especially when they are 
sound; nor should it be employed to separate 
sound teeth to introduce clasps. 

Filing the teeth is an operation against which 



126 INSTRUMENTS FOR FILLING. 

there has been, and still is, much prejudice, though 
without sufficient cause : whatever injury results 
from this operation, is mostly from the imperfect 
manner in which it is performed, and from subse- 
quent neglect of the tooth which has been subjected 
to it. A tooth skillfully treated with this instru- 
ment, and properly cared for afterward, will not be 
more liable to decay at the point operated upon, than 
at any other where the dentine may be exposed. 



CHAPTER V, 

SEPARATION OF THE TEETH. 

In most cases of proximal decay, the teeth, before 
the operation of filling can be performed, must be 
separated ; though cases are not unfrequent, where 
the space between them is sufficient to admit of free 
manipulation without this preliminary.. An imper- 
fect accomplishment of this first step in the process 
of filling, is a prolific source of the many failures, in 
proximal cavities, to attain to efficient and durable 
results ; for, unless this step be thoroughly performed, 
so as to make room for the free introduction and 
use of the various instruments requisite, no part of 
the work can be complete. Though the most com- 
mon object for which teeth are separated, is, to 
obtain space for free manipulation with the instru- 
ments in filling, yet there are various other objects 
for which they have been separated, but many of 
which are now better accomplished by other means. 
It is sometimes necessary to cut away more than 
would otherwise be requisite, in order to remove thin. 
friable edges of the cavity, so as to obtain sufficiently 



128 SEPARATION OF THE TEETH. 

firm borders. Teeth are in some instances separated 
for the introduction of clasps; a practice always to 
be deprecated, since it usually proves highly injurious. 
Though the practice was once very common, yet 
many of our best operators have now, with good 
reason, abandoned it altogether. At one time, too, 
it was a general practice to separate the teeth with 
the file to relieve a crowded condition ; but this, also, 
has been abandoned. 

There are two methods of separating the teeth : 
the one, to cut away a portion ; the other, to force 
apart by pressure, acting upon one or more teeth, as 
the circumstances admit. Formerly, all separations 
were effected with the file, and this of very crude 
form and cut; by which instrument, especially in 
unfavorable cases, much injury has been done. 
Though the file is a valuable instrument, one that 
no other could supply, yet, for removal of any con- 
siderable portion of dentine, it is not to be recom- 
mended. Its action upon inflamed dentine is exceed- 
ingly painful, besides being tedious and wearisome to 
patient and operator ; and it is liable to irritate the 
periosteum, and to increase inflammation. When a 
separation is to be made that requires the removal 
of a considerable portion of the tooth, the chisel, or 
heavy cutting instruments, are to be preferred. 
These, if of the proper form and temper, and 



SEPARATION OF THE TEETH. 129 

in good condition, are very efficient for the purpose, 
performing the work far more rapidly than the file, 
and far less unpleasantly to the patient. They effect 
the removal of sensitive dentine with but little or no 
pain, and without liability to increase the inflamma- 
tion, or to produce irritation or disease of the perios- 
teum. The force of these instruments is sustained 
by the entire attachment of the tooth, their pressure 
being applied almost in a line with its axis. Besides, 
by their use, the contiguous teeth are not liable to 
injury, as by the use of the file they often are. 

The manipulation with these instruments is very 
simple. For separating front teeth, the instrument 
is firmly grasped in the hand, the thumb placed on 
the points of the teeth, and the edge applied at the 
point or crown surface of the tooth from which the 
portion is to be removed, and pressed gradually 
toward the gums, but not thrust into tli€ interval as 
a wedge before it has freely cut its way. In this 
manner, as much of the dentine as it is desirable to 
remove, is cut off in a few moments. This class of 
instruments is invaluable for forming the V-shaped 
spaces between the bicuspids and the molars that 
have been popular with many operators, but are 
pointedly condemned by others. It requires a pro- 
longed use of the file to make these separations pro- 
perly; and hence the practice of attempting to fill 



130 SEPARATION OF THE TEETH 

proximal cavities without any separation at all, by 
operating through a small opening at the crown angle 
of the tooth, or a small hole drilled through its outer 
or inner portion. With the heavy cutting instru- 
ments, points upon the teeth, that the file cannot 
touch, are approached and operated upon with facility. 

But the method of separation by pressure is, in 
many cases, to be preferred, especially in the case of 
anterior teeth, whose natural form it is important to 
preserve. 

Till within comparatively a recent period, it has 
been the general practice to separate by gradual pres- 
sure ; and it is even yet the favorite method with 
many operators. But in almost all cases where 
separation is to be made by pressure, it can be done 
at once quite as well, if not better, than to prolong 
the process through several days ; there is economy 
of time, and the patient has far less to endure, and 
there is less liability of doing injury to the teeth or 
the parts about them. 

The anterior teeth, or those of single roots, yield 
very readily to a strong separating force, applied in 
the form of a wedge, notwithstanding the teeth may 
all be in contact with each other; though in some 
cases the teeth are so firmly set, and the parts about 
them so dense and unyielding, that it is with great 
difficulty they can be moved, without too much 



SEPARATION OF THE TEETH. 131 

violence to the parts. It is not generally practicable 
to attempt to separate the molar teeth by pressure. 

The method of effecting immediate separation is 
very simple ; it consists in forcing a wedge of some 
fine grained wood of medium resistance — orange or 
box wood — between the teeth to be separated, either 
by pressure with the hand, or better by the blows of 
a mallet. The wedge should be driven in at the necks 
of the teeth; and when they are very firm, an 
assisting wedge may be used, inserted between the 
points of the teeth, and receiving strokes alternately 
with the other. The assisting wedge should be of 
very dense wood, and driven in with great care, for 
its leverage upon the teeth is very great. When 
the required space is obtained, the wedge at the 
necks of the teeth should be driven tightly in, and 
the other withdrawn. If all the teeth in the vicinity 
of those to be separated stand in contact, the resist- 
ance to separation, whether by immediate or gradual 
effort, will be greater. 

The rapidity with which the operation may pro- 
ceed, and the extent to which it may be carried, 
will be determined by the tolerance of the parts to 
the movement, which should not be greater than the 
elasticity of the tissues will permit, not the slightest 
laceration or rupture should be made ; again great 
care should be observed, lest strangulation of the ves- 



132 SEPARATION OF THE TEETH. 

sels that enter the roots, pass to and supply the 
pulp, he effected; this would be far more liable to 
occur in the teeth of young persons, or before ma- 
turity. There is in adults, however, a great diversity 
in their susceptibility to injurious influences. 

Mimy operators still prefer gradual separation, by 
pressure. In order to secure the most successful 
results, the conditions of the parts should be strictly 
observed. The gums, periosteum, etc., should be in 
a healthy condition; for much injury may be done 
by attempting to separate teeth by pressure, when 
the contiguous parts are in an irritable state. In 
persons of a neuralgic diathesis, in those whose vital 
energy is weak, and particularly in those whose con- 
stitutional tendency is inflammatory, this operation 
is scarcely admissible. If, in such cases, it is at- 
tempted at all, it should be proceeded with very 
carefully and gradually, and should be preceded by 
constitutional treatment. There are many cases in 
which it is best to make the separation partly by 
pressure, and then to complete it by dressing off the 
thin, friable edges of the cavity with the cutting 
instrument or file. Whether the process is to be wholly 
or only partly accomplished by pressure, should be 
determined beforehand. 

Various materials have been employed for sepa- 
rating the teeth by gradual pressure, the chief of 



SEPARATION OF THE TEETH. 133 

which are cotton, wood, India rubber, and ligatures. 
The condition and character of the parts to be 
operated upon, will indicate the material best adapted 
in any given instance. In a good constitution, with 
the teeth firmly set, and the contiguous parts healthy, 
wood or India rubber may be applied ; but in cases 
of an opposite character, a more yielding and tract- 
able material is indicated. The degree of pressure 
to be applied and continued, will be determined by 
the susceptibility of the parts to irritation. Soreness 
usually occurs in a few hours after the introduction 
of the material. The pressure should be gradual and 
constant, slight at first, and increased in force as the 
patient will bear ; the increase being made every clay, 
and continued till ample space is obtained. The 
time necessary for the completion of this process is 
from ten to twelve days ; only one separation should 
be made at a time. The teeth should be retained 
apart till the soreness has abated, before the opera- 
tion. If not thus retained too long, they will return 
to their former position. It is by some supposed that 
separation by pressure is admissible only in the case 
of the young, or those under thirty years of age. It 
is true that they are the most susceptible ; but the 
operation is, under favorable circumstances, proper at 
any age. 



CHAPTER VI. 

FILLING TEETH. 

The operation of filling teeth is an interesting and 
important one, requiring for its successful accomplish- 
ment peculiar talent and large experience. It is the 
only means as yet ascertained of completely effecting 
the object for which it is employed, namely, arrest of 
decay and preservation of the organs. Therapeutic 
agents avail but little here, so low is the organization, 
and so feeble the vital power. Nature, so efficient in 
more highly organized structures, does comparatively 
but little, in disease of the teeth, toward arrest or 
restoration. Yet, on the other hand, these organs 
are less liable to decomposition by the action of 
foreign substances ; indeed, the enamel is almost 
invulnerable to any agents to which it is ordinarily 
exposed. The dentine, however, is more easily acted 
upon, and, when there is defect in the enamel, is very 
liable to injury. 

Scarcely an individual in our country arrives at 
mature age with a perfect set of teeth ; indeed, nine- 
tenths of our people have decayed teeth at an early 
period of life. Hence, for beautifying, preserving, 



EXAMINATION. 135 

and supplying these organs, art is in constant requi- 
sition ; and, in these respects, great achievements 
have been made. In the operation of filling the 
teeth, especially, the achievements are conspicuous ; 
and here is scope for the highest skill. Every suc- 
cessive step in the process of filling a tooth demands 
a complete and conscientious application of the most 
efficient and best adapted formulas of the art. In 
the following remarks, it is proposed to analyze this 
whole process, examining, in their order, the various 
steps necessary to be taken, and endeavoring to incul- 
cate the true methods of accomplishing them. 

EXAMINATION. 

When a case is presented, there should first be a 
thorough examination, since by this all the subse- 
quent work will be modified. The points to be noted 
in the examination are as follows : 

The temperament ; the present health ; the consti- 
tutional tendencies ; the secretions, — the saliva and 
mucus ; the mucous membrane and the gums ; the 
constitution and condition of the teeth; the num- 
ber of them remaining in the mouth ; the number 
affected ; and the extent and nature of the decay, 
and the character of the agents producing it. By 
the examination we ascertain how to proceed in the 



136 FILLING TEETH. 

operation ; if much or but little labor is required ; 
whether the operation will be a simple or a difficult 
one; and if difficult, what circumstances render it so; 
and, besides, some conclusion is arrived at in regard 
to the precise means to be employed for obtaining the 
desired result, as well as the permanency of that 
result. 

OPENING. 

The next step is to open the cavity of decay, so 
that it may be approached and operated upon at all 
points. The particular manner of performing this is 
determined by the extent of the decay, and its posi- 
tion upon the tooth. In all cases the opening should 
be such as to give free access to all parts of the 
cavity, for effectually removing the decayed portion, 
for perfectly forming the cavity, and for introducing 
and thoroughly consolidating the filling. In central 
crown cavities of the molars and bicuspids, the pro- 
jecting or pendent portions of enamel should be cut 
away. There are cases, however, where such por- 
tions are firm and not liable to be broken, and where 
they can be well sustained by filling under, in which 
it is admissible to leave some projection. This is 
true of only those teeth which are of good, firm 
texture. There are two objections to these abrupt 



OPENING. 



1ST 



projections of enamel : it is very difficult, and in 
many cases impossible, to fill perfectly beneath such 
portions ; and again, they are liable to be broken 
down during mastication. 

For opening up these cavities, in many cases the 
bur drill alone will be quite sufficient ; those of dif- 
ferent sizes being employed, to open up the orifice 
gradually, so that too much violence may not be clone 
to the teeth. In all very small cavities, the bur is 
all that is required, except in decayed fissures. 

In cases where the decay is more extensive, and 
the cavity larger, the chisel or heavy cutting instru- 
ment, in connection with the drill, will be found very 
useful. Fig. 41 represents valuable forms of these 
instruments. 

Fig. 41. 




An instrument first brought to the notice of the 
profession by Dr. I. Forbes, is very valuable for open- 
ing and enlarging crown cavities of the molars. It 
consists of a socket-handle, which receives a screw- 
clamp, and this receives the bits; which arc o^ 



138 



FILLING TEETH. 



various forms, such as the gouge-, chisel-, and V- 
shape : these fit into the clamp, and are grasped by 

Fie. 42. 




zn 



it, as it is screwed into the handle. (Fig. 42.) By 
the use of these instruments the operation will be 
very much facilitated, and less jarring communicated 
to the tooth ; but after it is used, the bur or fine file 
will be required to give a smooth, uniform border to 
the cavity. In these cases, the orifice should be 
almost or quite as large as the cavity within. In 
proximal decay, the cavity must be sufficiently 
exposed to enable the operator to see distinctly into 
it, and to manipulate freely, in all parts of the 
operation. These cavities may be exposed by the 
use of the chisel, file, or pressure. 



REMOVAL OF DECAY. 



After the cavity is opened, the next step in order 
is the removal of the decayed dentine. As a general 
rule, this should be entirely removed. There is, 



REMOVAL OF DECAY. 139 

however, some variety of opinion upon this subject. 
This difference of opinion is in regard to cases where 
an entire or a partial decomposition of the dentine 
has taken place quite to the pulp, where, by its 
removal, the pulp would be exposed. It is main- 
tained by some that decayed dentine affords a better 
protection to the pulp than any artificial covering; 
and hence it is better to let it remain, since its 
adaptation is more complete ; and it is not in every 
sense a foreign substance. 

On the other hand, it is contended that the de- 
cayed dentine, being in an abnormal condition, will 
irritate, and in many cases ultimately destroy the 
pulp. And again, that there is danger of making 
undue pressure upon the pulp, in filling on such soft- 
ened portion. 

In many cases, it is maintained that partially de- 
composed dentine will become dense again, if pro- 
tected from the influence of foreign agents that 
decompose it. This sometimes would seem to be 
true. For in some cases, where fillings have been 
introduced into cavities, at the bottom of which a 
softened portion of dentine covered the pulp, on 
removing them in from one to five years afterward, 
the whole walls of the cavity were found to be 
equally and normally dense. This, perhaps, would 
occur only in good constitutions, and under favorable 



140 FILLING TEETH. 

circumstances ; but with such constitutions and cir- 
cumstances, where the softening is not too extensive, 
and the decomposition but partial, it may be per- 
mitted to remain, with a strong probability of a 
favorable result. This would certainly be better 
than to cut it all away and expose and perhaps 
wound the pulp, and then endeavor to cover it with 
some wholly foreign material that would not be per- 
fectly adapted to it, that would press a little too hard 
at one point, and not touch at another, and that would 
be quite as liable to be pressed down on the pulp as 
the softened dentine. ' 

In this discussion, much depends upon the point 
whether partially decomposed dentine can retain its 
vitality. This it is not now proposed to consider. 
There are some particulars in regard to the removal 
of decay, however, about which there is no diversity 
of opinion : first, that all decomposed dentine should 
be removed from all parts of the cavity, where the 
pulp would not be exposed or injured thereby; and 
that in all cases it should be entirely removed from 
the lateral walls of the cavity, and especially from 
the vicinity of the orifice. Even discolored dentine 
should be removed from this point. 

Dentine often becomes changed in color when 
there is no apparent decomposition; such portion is 
usually, though not always, without vitality. It is 



REMOVAL OF DECAY. 141 

not important to remove such changed portion, except 
for the appearance of the tooth ; it will produce no 
change upon the living or normal part beyond it; 
and it is better material to be in contact with the 
living part than the metal of which the filling is 
made. 

Decayed dentine is readily removed with the exca- 
vators. In any given case, such instrument should 
be selected as would he best adapted for the purpose, 
as well in regard to size and the form of its edge, as 
to the curvature, or inclination, of its shaft. The 
edge of the instrument should come upon the walls 
of the cavity at such an angle as to accomplish the 
work most efficiently. It should be very sharp, and 
pressed firmly to the bottom of the decay at one side, 
so as to remove the principal part at one cut. With 
the proper instrument, and that in the right con- 
dition, all the decay should be removed from any 
cavity by a very few, firm, steady strokes. By this 
method less pain is caused the patient, and the work 
of the operator is facilitated. It is intolerable to 
think of being subjected to an awkward, clumsy 
hand, with a dull, ill-shaped excavator, scratching 
upon the surface of a decayed tooth, for a length of 
time, apparently to the patient, interminable. 



142 FILLING TEETH. 



FORMING CAVITIES. 

The next step in the operation is the formation of 
the cavity. By this the cavity is so formed that it 
will retain the filling when properly introduced. In 
very few cases is the cavity of proper form when the 
decay is removed. Much time, patience, and labor 
are required of the operator, for the proper accom- 
plishment of this part of the work, and much endu- 
rance on the part of the patient. Excavation is often 
necessary to give a regular form to the cavity ; and 
in this process there are several particulars worthy of 
consideration. The great object, however, is to give 
to the cavity such a form as will most certainly re- 
tain the filling in place. The cutting for the forma- 
tion of the cavity should be accomplished with the 
least possible loss of healthy dentine ; this is a point 
upon which good judgment should be exercised. 
The strength of the walls of the cavity, and the 
ability of the parts to withstand the pressure, both in 
the introduction and consolidation of the filling and 
in the act of mastication, should be well noted. It 
may be regarded as a rule from wdiich there should 
scarcely ever be a departure, that the enamel should 
never be encroached upon in excavating to give form 
to a cavity. When there is but a lining of dentine 



FORMING CAVITIES. 143 

at any given point on the enamel, after the decay is 
removed, it should remain for the preservation of the 
enamel ; it should not he cut through either by pits 
or by grooves, much less should any considerable por- 
tion be removed. 

There are cases occasionally in which the dentine 
is wholly decayed, and its removal lays bare the 
enamel ; when such a case occurs, the enamel should 
be retained as perfect as possible, and no attempt 
made to form pits or grooves in it. The reason for 
this is found in the friability of the enamel. 

It may be. regarded as an axiom, that where it is 
necessary to cut the healthy dentine to give proper 
form to a cavity, it should be done at that part of 
the cavity, where the tooth will suffer least from the 
loss. The precise point and amount of cutting will 
be determined by the form and size of the cavity, and 
the amount of solid dentine remaining after the decay 
is removed. 

In small cavities, where there is sufficient material 
to work upon, the object is to give the cavity a 
regular form, and make the retaining points where it 
is most convenient. 

In large cavities, where one side of the tooth is 
weak, places must be selected for making the retain- 
ing points, that will not affect the weak point. Fre- 
quently, in proximal decays of the anterior teeth, the 



144 FILLING TEETH. 

labial and palatal walls are friable, and would be 
easily broken ; much cutting upon such walls would 
not be admissible. Again, the decay often extends 
toward the point of the tooth, down to the union of 
the labial and palatal plates of the enamel; in cases of 
this kind, all that can be done at this point is to re- 
move the decay; and fracture will sometimes occur, 
even in accomplishing this. 

In some instances, as in the crown cavities of the 
molars, the cavity will be nearly or quite of proper 
form when it is perfectly opened up, and the decay 
all removed. This is the case when the decay is 
confined to a simple perforation of the dentine, with- 
out any lateral extensions. In proximal cavities, 
there is always more or less excavation of the solid 
dentine required, to give the cavity proper form. 

There is no definite rule for the formation of cavi- 
ties, that will be applicable in all cases. The form 
will be modified by the tooth, the position of the 
decay upon it, and the extent and ramifications of 
the decay and the manner in which it is to be filled. 
' It is given, by some, as a rule, that the depth of a 
cavity should be equal to its least diameter. This is 
a direction, however, of no general application, for 
many cavities will be much deeper than the greatest 
diameter, as in crown cavities of the molars ; and the 
reverse will often occur, as in labial cavities of the 



FORMING CAVITIES. 145 

superior incisors, and in proximal cavities of the 
molars, in which it would be impossible to make 
anything like an approach to this rule, without ex- 
posing the pulp, and even cutting through its chamber. 

A general direction, and one that we think good, 
and applicable in many cases, especially in crown 
cavities of the molars, and in almost any of the deep 
perforations by decay, is, to make the walls of the 
cavity as nearly as possible parallel with one another. 
This rule is applicable in almost all small cavities. 

In medium or large-sized cavities, it is admissible 
to leave them slightly larger at the bottom than at 
the orifice, if circumstances require ; a large cavity of 
this form can be perfectly rilled, when a small one 
could not, from the fact that, in the former, there is 
more room to operate in introducing and consolidating 
the filling. 

Cavities that are larger within than at the orifice, 
should have their walls perfectly plain, smooth sur- 
faces, free from transverse grooves or depressions, so 
that the gold may be perfectly adapted to them. 

It is sometimes necessary to leave a cavity slightly 
larger at the orifice than at the bottom. This may 
be done by a converging inclination of the wall of 
one or more sides of the cavity. When there is an 
inward inclination of the wall at one side of the 
cavity, the general form may be such as to retain a 



146 FILLING TEETH. 

filling perfectly, for there may be two opposite sides 
parallel, or even divergent ; in that case, the axis of 
the cavity will not be in the direction of the center 
of the crown. 

Two opposite sides may converge and the others 
diverge, and a filling be retained firmly. When two 
contiguous sides have the same converging inclina- 
tion, making the orifice larger than the interior, if 
the walls are smooth, plain surfaces, a filling will not 
be retained ; but retaining points may be made by 
forming transverse grooves, or pits upon them, and 
by this means the filling be firmly retained. As a 
general rule, it will be necessary, when the orifice is 
larger than the cavity within, to make grooves or pits 
on the walls. For this purpose the diamond point 
excavator is invaluable. 

If the cavity is large, and the walls near the orifice 
thin, and liable to be broken, the situation of the 
grooves or under-cutting should be farther within the 
cavity than if the walls are firm out to the edge. 
Sometimes it is best to make little pits at the bottom 
of such cavities for retaining points. In cases where 
it is necessary to make an under-cutting, one or two 
little transverse grooves upon one side will be suffi- 
cient, and in no case on more than two sides, leaving 
the others perfectly plain surfaces. 

In the formation of retaining points in difficult 



FORMING CAVITIES. 147 

cavities, there is considerable diversity of practice — 
under-cutting and grooving have been very com- 
monly employed. Another method has been very 
frequently adopted during the last three or four 
years, namely, that of drilling little holes or pits into 
the dentine at the most favorable points, these taking 
different directions. This kind of retaining points is 
much better calculated to answer the purpose, in 
filling with crystal gold, or adhesive foil by Dr. 
Arthur's method, than with the ordinary foil after 
the old methods. When these perforations are made 
at different inclinations, and then perfectly filled with 
adhesive gold of any kind, the filling will certainly 
be retained in place. For making these perforations, 
a small square-edged drill is the proper instrument. 

Such retaining points are seldom or never required 
in crown cavities of the molars ; but in proximal 
cavities they are frequently employed with great 
advantage. In forming them, great care should be 
exercised, lest the pulp-chamber is encroached upon 
by the instrument. In almost all cases, the proper 
point for forming them is in the cervical wall of the 
cavity. 

Another particular to which attention should be 
given is the border of the orifice. It should always 
be an object to secure an even, smooth, and strong 
border to the orifice of the cavity. It is impossible 



148 FILLING TEETH. 

to make a good finish with a rough, uneven border ; 
the filling is also more exposed to injury by mastica- 
tion. The integrity of a smooth, plain surface is per- 
fectly retained under influences that would break up 
and destroy an uneven one. It is also very desirable 
to have a firm margin; to obtain this, it is often 
necessary to cut away more, than would otherwise be 
desirable. A smooth, firm border should not be sacri- 
ficed for the form, and especially in the posterior 
teeth. It is very objectionable to some persons to 
have the perfect form of the front teeth marred or 
changed ; but it should be remembered that even a 
front tooth, one-third cut away, and so filled as to be 
permanently preserved, is far more valuable than an 
artificial one. 

Another particular that should always be observed, 
is, to obviate all acute angles. These are seldom or 
never found in proximal cavities of the molars and 
bicuspids ; occasionally they are found in proximal 
cavities of the cuspids, and frequently in proximal 
cavities of the incisors, particularly at that part of 
the cavity next to the cutting edge of the tooth. 
Such angles are very often found also in crown 
cavities of the molars, where there is an extension 
of the decay along one or more of the fissures of the 
crown. 

It is difficult— almost impossible — to fill perfectly 



FORMING CAVITIES. 149 

a sharp angle, and hence the necessity of obliterating 
such when they occur. This may be done either 
with a small delicate cutting instrument, or with a 
small bur drill. It is an operation requiring great 
care and delicate manipulation, at least so far as the 
anterior teeth are concerned. When a sharp angle 
occurs in the proximal cavities of the front teeth, 
it is usually near the cutting edge of the tooth, 
just at the union of the labial and palatal plates of 
enamel. A small chisel-shaped instrument is very 
good for cutting out such angles : indeed, in fissures 
of crown cavities of molars, where the decay extends 
backward, the straight, chisel-shaped instrument is 
just adapted to this purpose ; but when there is an 
anterior extension, the instrument should be curved 
to almost a right angle, and forced down by pressure 
of the thumb of the left hand. Some good operators 
recommend a slight reaming at the orifice of all cavi- 
ties, where it can be accomplished. The object of 
this is twofold : to remove the sharp angle at the ori- 
fice of the cavity, as it is liable to be roughened in 
putting in the filling ; and to give a better margin to 
the filling. In making this bevel, the bur, if one is 
used, should be but little larger than the orifice of the 
cavity. The cutting should be but slight — just suf- 
ficient to remove the sharp corners ; much cutting here 
would give too thin and yielding an edge to the filling. 



150 FILLING TEETH. 



DRYING CAVITIES. 

After a cavity is properly formed, it should be 
thoroughly cleaned and dried. Every particle of de- 
tached bone or foreign substance should be removed ; 
during the excavation every thing should be kept 
out, every fragrant removed as soon as it is de- 
tached ; but generally there is something of the kind 
to remove after the cavity is formed. This may be 
done probably better with a syringe than by any 
other method ; this, however, used in connection with 
a moist lock of cotton on a probe, will serve to re- 
move every extraneous material that may be in the 
cavity. Any foreign substance remaining in the 
cavity prevents a perfect adaptation of the gold to 
the part, and consequently as perfect an attachment 
as would otherwise be obtained. After washing out 
thoroughly, wipe out with successive locks of dry cot- 
ton, till all the moisture is removed. The ordinary 
cotton will not accomplish this very effectually. By 
washing cotton in sulphuric ether, it is much im- 
proved for this purpose. The ether removes a peculiar 
oily substance from it, and thus increases its capacity 
to absorb moisture. Ether or chloroform will either 
answer the purpose ; or boiling the cotton in water 
in which there is a small portion of carb. soda, or 



DRYING CAVITIES. 151 

some such alkali, for a short time, will accomplish 
the same thing. Bibulous and blotting paper have 
been employed for this purpose ; and by some they 
are preferred. Prepared flax has likewise been used. 
Either of these is no better than cotton well prepared. 
The respect in which the paper is any better than 
common cotton, is, that it has the same treatment in 
effect as the prepared cotton. 

With none of these things can a cavity be made 
absolutely dry. It is not necessary to have absolute 
dryness to make a good filling, yet a more perfect 
filling can be made where that condition is obtained. 
Gold takes a better hold upon a perfectly dry, than 
upon a moist surface. This is quite apparent in the 
following experiment : Place two or three blocks of 
gold in any ordinary cavity, wiped as dry as possible, 
and press them firmly in place, consolidating them as 
much as would be done in filling, and then test the 
attachment by removal. Afterward reduce the same 
cavity to absolute dryness, take the same amount of 
gold, in the same form, and place it in the cavity, 
and consolidate as before, at the same point in the 
cavity; and then test its attachment in the same 
manner. The latter will be found much more firmly 
attached than the former. 

But it is objected that this is useless, inasmuch as 
the natural moisture of the tooth is removed, by pro- 



152 FILLING TEETH. 

during absolute dryness, and that this will soon 
return, and then the cavity will be no dryer than it 
could have been made with good cotton or paper. 
Admitting this, perfect dryness will remain long 
enough for the introduction of the rilling. And if 
this is facilitated by absolute dryness, and a better 
adaptation and attachment obtained, then it is de- 
sirable to obtain that condition. 

It has already been remarked that perfect dryness 
can not be obtained with cotton or paper. To warm 
these on a hot metallic plate, after being wrapped on 
the instrument, will very much increase their effi- 
ciency in removing moisture. Asbestos wrapped on a 
small bulb-pointed instrument, and heated, is very 
good for drying out cavities ; with it, perfect dryness 
can be obtained, as it can be reheated and applied 
as often as necessary. To prepare this, select a 
proper-sized bulb-pointed instrument; a worn-out bur 
drill answers well ; and fold over its fibers of asbestos, 
passing them a little way beyond the bulb on the 
shaft of the instrument, and there binding them 
firmly on with fine platinum wire ; and the instru- 
ment is ready for use. Another method of obtaining 
perfect dryness — one that is very certain in its 
result — is to throw a jet of warm air into the cavity. 
This is accomplished by a little instrument, simple 
in structure and easily used. (Fig. 43.) It consists 



DRYING CAVITIES. 153 

of a small blowpipe with a cylinder an inch long, 
and half an inch in diameter ; this is placed down 
within two inches of the point of the instrument. 

Fig. 43. 



This cylinder is either made of very heavy metal, or 
rilled with wire or something that will retain heat ; 
on the other end is attached a stiff India-rubber ball 
with an eyelet opening one-fourth inch in diameter. 
By placing the thumb upon this opening, and making 
compression, a jet of air is forced through the point 
of the pipe, and the cylinder being previously heated, 
the temperature of the jet will be governed by that 
of the cylinder, and the velocity with which it is 
forced through the instrument. This jet thrown 
into a cavity that has been made as dry as possible 
by wiping, soon makes a very perceptible change, the 
walls becoming whiter than before. This we con- 
sider the most desirable condition in respect to dry- 
ness, that can be obtained. 



154 FILLING TEETH. 



INTRODUCING THE FILLING. 



Having, in all the steps for the preparation of the 
cavity, made thorough work, the next thing to be 
accomplished is the introduction and consolidation of 
the filling. The manner of performing this part of 
the work will be governed by the kind of material 
employed, and also, somewhat, by the form of the 
particular material, as well as the method adopted. 
Some materials, as gold, for instance, may be used in 
three or four different forms, each involving a princi- 
ple peculiar to itself; and each of these forms is 
susceptible of being used in different ways. It is 
proposed to describe, as clearly and concisely as 
possible, the various methods of filling that have 
been found efficient. This is the more important since 
different operators differ in their election of methods ; 
some preferring one, others another; the result of 
mere choice, habit or some peculiar fitness. 

The first method for consideration is that of filling 
with ordinary non-adhesive gold foil. The principles 
applicable to the use of this kind of foil also obtain in 
the use of foils of other metals. Gold is used far more 
than any thing else. The common, and, indeed, the 
almost universal method of using foil, in the early 
periods of the profession, was in the form of a roll, or 



INTRODUCING THE FILLING. 155 

rope, as it was sometimes called. By this method, 
the foil is cut into strips from one-third of an inch to 
two inches wide, the w 7 idth being governed somewhat 
by the size of the cavity to be filled. This strip is 
then rolled lengthwise, forming a loose roll. The 
compactness of the roll should depend upon the thick- 
ness of the foil, and the size of the points with which 
it is to be condensed; the smaller the points, the 
more compact the roll may be. 

It may be introduced either with the condensing 
instrument or with the plugging pliers (improperly 
sometimes called plugging forceps). 

If with the former, it is taken up at one end on 
the point of the instrument, and passed to the bottom 
of the cavity; and that portion within the cavity is 
pressed firmly against the wall where it is desirable 
to begin the filling. There is no definite uniform 
point in cavities, at which to begin the introduction 
of the gold ; usually, however, in crown cavities of 
the molars, at the posterior wall. At whatever point 
the filling is commenced, the cavity should be so 
formed that it will retain the first portion of gold 
introduced; and this may be done by forming a little 
pit or groove for the reception of the portion first 
introduced. This is a particular that can not with 
impunity be neglected. The gold should never change 
its position after it is pressed to the wall of the cavity; 



156 FILLING TEETH. 

for its position can not be changed, except at a sacri- 
fice of the adaptation, after it is condensed. The end 
of the roll being placed in the cavity, it is seized far 
enough without the cavity to form a fold that will 
extend to the bottom, and protrude about one line 
beyond the border of the orifice. This fold is pressed 
firmly upon the preceding portion of gold and adjacent 
walls. Thus fold after fold is introduced, passed to 
the bottom of the cavity, and, protruding from the 
orifice, consolidated firmly, each portion as it is intro- 
duced, being perfectly adapted to the walls of the 
cavity and the preceding portion of the filling. 

It is important to obtain as complete an adaptation 
of the filling to the walls of the cavity as possible ; 
and in order to accomplish this the center should not 
be filled too rapidly. The gold is thus introduced 
fold after fold till the cavity is full. When it is filled 
to two-thirds of its diameter, the gold should then be 
adjusted to all the remaining walls of the cavity, and 
the last portions of gold introduced somewhere in 
the body of the filling, certainly not next to any wall 
of the cavity. A more thorough adaptation of the 
gold can be made to the walls of the cavity, by this 
manner of arranging it, than by introducing the last 
portion at one side of the cavity. There is less lia- 
bility of fracturing a frail tooth by placing the gold 
on the walls first, and terminating the introduction 



INTRODUCING THE FILLING. 157 

of it at or near the center of the filling. It is a very 
common practice to introduce the gold rather loosely, 
or without much condensing, and after being intro- 
duced in this manner, to condense by forcing into it 
a wedge-shaped instrument at various points, and 
rilling these perforations with small rolls of gold ; 
continuing to use the wedge-shaped instrument as 
long as it can be forced into the filling. This method 
is by no means as efficient as that of condensing each 
portion as it is introduced. By the latter plan the 
filling can be made uniformly dense from the surface 
to the bottom of the filling. This can not be done 
by the use of the wedge-shaped instrument ; it will 
compress most at its largest diameter, that is, at the 
surface of the plug. 

In no filling, even when the walls of the cavity are 
parallel, will a uniform density throughout be ob- 
tained by perforating with the wedge. The filling 
would be most dense at the surface, and less so the 
farther into the filling we go. This method is objec- 
tionable for condensing the fillings on the masticating 
surfaces of the molars ; for in the act of mastication 
the inner portion would yield, and the surface of the 
filling would be crowded down into the cavity, and 
the dentine within the orifice become exposed and 
decay be the result. In proximal fillings this objec- 
tion would not have the same force. In pressing an 



158 FILLING TEETH. 

instrument of a wedge form into a filling with suffi- 
cient force to condense the mass, there would be great 
danger of breaking a weak wall of the cavity. The 
principal pressure is lateral, and would consequently 
come upon the side of the tooth. 

In crown cavities of the molars where there is any 
considerable inward expansion of the cavity, that 
method of condensing would be wholly inefficient ; it 
would not render the inner portion dense enough to 
support the surface of the plug, and it would be 
forced dowii, and necessarily be loose. In filling the 
proximal cavities of the incisors, it is very objection- 
able on account of the great liability of breaking the 
inner and outer walls, which are usually quite thin. 

In preparing the foil for filling, some operators tear 
off the foil in irregular pieces, and form into little 
balls or pellets, round and loosely rolled, correspond- 
ing in size with the cavity to be filled. These pellets 
are placed in the bottom, if a crown cavity, and at 
one side, if a proximal cavity, and condensed with a 
sharp-pointed instrument, attaching one pellet to 
another till the cavity is full. This mode is not so 
good as that previously referred to, unless the gold is 
in a condition to weld perfectly; there is no con- 
tinuous portion from the bottom to the orifice of the 
cavity ; and the outer portions are liable to become 
detached. Both of these methods of arranging the 



CYLINDER OR BLOCK FILLING. 159 

gold are objectionable in one particular, namely, the 
irregularity of the leaves or laminae of the foil ; these 
are placed in the cavity without any regard to regu- 
larity, and the consequence is, that without very 
great care, far less gold will be introduced than by 
some other arrangement. Far more difficulty is 
experienced in obtaining a uniform and equal density 
than when the laminae are placed smoothly together. 
Another method of preparing the foil is to fold it 
into from ftmr to twelve thicknesses, then cut off 
strips in width corresponding to the diameter of the 
cavity. The strip thus prepared is introduced in the 
same manner as the roll, except that as each fold is 
inserted, it is placed smoothly against the preceding 
portion, and kept smooth and free from wrinkles. 
By this arrangement very little force is required to 
bring the folds in perfect contact. Some care and 
skill will be necessary to bring the instrument to 
bear upon the whole surface of the fold. More gold 
can be put into a cavity in this manner than in rolls 
or pellets, unless these are used in very small portions, 
and condensed very thoroughly as they are put in. 

CYLINDER OR BLOCK FILLING. 

Another and in some respects far preferable 
method, is filling with cylinders or blocks. Some 



160 FILLING TEETH. 

of the advantages of this method over that just 
described, are the following: the rilling can be intro- 
duced far more rapidly ; and the laminae, or leaves of 
foil, take a more perfect position in the cavity, and 
consequently the structure of the rilling is better. 
The form of the cavity should be much the same as 
that for any other method of rilling; there should be 
some retaining point so situated that the first block, 
or blocks, can be fixed firmly in place, so that there 
will be no liability of loosening during the subsequent 
part of the process. It is important to have such an 
arrangement, as otherwise it would be necessary to 
employ an instrument in the left hand to retain the 
first blocks in situation, till enough were introduced 
to bind the whole by pressure upon two opposite 
points in the cavity. 

Forming Blocks. — For forming blocks, use any 
number of foil that may be desired, usually No. 4 or 
6, and either lay four to six sheets together, or fold a 
single sheet into that number of thicknesses; then 
cut off, from the sheets thus prepared, strips about 
one-third to one-fourth wider than the depth of the 
cavity to be rilled; which are then rolled on a 
small three or four-sided broach — the three-sided is 
better; this instrument should be very small; no 
larger, indeed, than is necessary for strength. Its 
sides should be perfectly smooth, and its angles 



CYLINDER OR BLOCK FILLING. 161 

sharp ; ordinarily it should not taper, or at least very 
slightly. For forming the conical blocks, some prefer 
the tapered broaches, but they can be as well made 
on the parallel-sided instruments. The strip being 
taken between the thumb and the index ringer, is 
rolled on the broach equally, till the block or cylinder 
is large enough, when the strip is broken off. The 
sizes of the principal part of the blocks should cor- 
respond with the sizes of the cavities to be filled. 
Different sizes and forms will be required in almost 
all cases. Relatively large cylinders may be em- 
ployed for the principal part of the filling. If the 
walls of the cavity are parallel, almost all the blocks 
may be truly cylindrical; but if there is an under- 
dipping of one or more of the walls, the blocks 
adjusted to that particular part should be cone-shaped, 
corresponding to that under-dipping. A number of 
small graduated cone-shaped blocks, of different de- 
grees of density, will be required for completing each 
filling; as the aperture becomes smaller, smaller 
blocks will be needed. The cone-shaped blocks are 
formed, by gradually running the strip back from the 
point of the instrument as it is wound on ; greater or 
smaller taper can be given to it, as the strip is run 
less or more rapidly back from the point. The 
density of the block can be regulated by the firmness 
with which the strip is held between the thumb and 



162 FILLING TEETH. 

finger; upon which it is well to have a fine silk or 
India-rubber covering to protect the gold from the 
perspiration of the hand. There -are other methods 
of forming blocks. They may be made square, by 
making a great number of folds — fifteen to thirty — 
and from this, cutting strips as before directed, and 
then from these heavy strips cutting off the blocks of 
the desired size, which will then be flat or nearly 
square. In one respect these blocks are objection- 
able : the edges, when they have been cut off, are 
rendered dense by the action of the shears, so that 
they clo not possess the uniform density or consistence 
of the rolled blocks, and it is impossible to adapt 
them as perfectly to the walls of the cavity, or to one 
another. This objection, however, may be obviated 
by cutting off the blocks with a very fine saw. 

Another method of forming blocks, first employed 
by Dr. Blakesley, is to roll a sheet of No. 5 foil into a 
rope, and cut off from it blocks corresponding with 
the size of the cavity to be filled. These are liable 
to the same objection as those last mentioned, the 
shears hardening them, when they are cut off. They 
are subject to the additional objection, that the folds 
of foil are not as regular as by either of the other 
methods. But by proper manipulation, with the gold 
prepared in this manner, superior fillings may be 
made. Another method of preparing blocks is by 



CYLINDER OR BLOCK FILLING. 163 

cutting a sheet of foil into two or three pieces, then 
roll them diagonally on a steel wire or rod; the size 
of this wire will he determined by the required length 
of the blocks, as there should be blocks of different 
lengths, the wires should be of different sizes, and range 
from No. 2 to No. 12 of White's bur gauge plate. 
The size of the wire will be determined by the depth 
of the cavity. The wire being withdrawn, the foil is 
compressed to a strip. These strips are now rolled 
squarely upon a No. 20 steel wire ; the size of the 
cylinder being determined by the size and form of the 
cavity to be filled. These may be used either in 
their cylindrical form, or compressed and doubled. 
The cavity formed, and the blocks prepared,. the next 
step is their introduction. 

Introducing the Blocks. — For placing the gold into 
the cavity the plugging pliers will be required ; the 
points of which should be curved, so as to make the 
most perfect approach to the cavity. The points, 
too, if properly formed, may be used to some extent 
for condensing the blocks. All things being ready, 
with suitable napkins and guards for the protection of 
the cavity against the encroachment of moisture from 
the saliva and breath, the fingers of the left hand 
should press upon the napkin, and also hold away the 
soft parts. If there is an angle, a small block should 
be first introduced with the pliers into the proper 



164 FILLING TEETH. 

position, one end upon the bottom of the cavity, and 
the other protruding from the orifice, and pressure 
then be made upon it to consolidate it, and force it* 
into its position against the wall of the cavity. This 
may be done with the pliers, or better with the 
instrument represented by Fig. 21. The part of the 
instrument brought to bear upon the gold should be 
roughened either longitudinally or transversely, so 
that a proper surface may be left for the reception of 
the succeeding portions. The largest blocks are then 
introduced and consolidated successively as described, 
the end of each left protruding, till the cavity is 
filled; each portion as it is introduced, should be per- 
fectly condensed. The gold should be filled in faster 
at the sides of the cavity than in the center, thus 
being disposed round the walls till it meets at a point 
opposite the place of beginning; and thus it is adapted 
to all the walls of the cavity before it is entirely 
filled, the last portions being introduced somewhere 
near the center of the filling. As the cavity dimin- 
ishes by the introduction of the gold, the small and 
more dense blocks will be required ; which should be 
forced in and condensed, by crowding the instrument 
(Fig. 23) down against the side of the cone. Some 
operators terminate the filling against the wall of. the 
cavity, forcing down the blocks and compressing, as 
above, till it is full. By this method there is danger 



CYLINDER OR BLOCK FILLING. . 165 

of fracturing the tooth, breaking down the wall of 
the cavity, where the filling is terminated. Another 
method is to fill up the cavity principally with blocks, 
and to put in the last part of the filling in the strip, 
fitted in from the bottom to the orifice. The objec- 
tion to this method is, that unless adhesive foil is 
employed, the portion inserted in the strip is liable 
to be displaced, and in this way the whole, filling 
become destroyed. 

Another method of arranging this kind of filling, 
particularly when the bottom of the cavity is irreg- 
ular, is to make a large, flat pellet, condense it firmly 
to the bottom, and set the blocks upon this for a 
foundation. By this method there is a more perfect 
adaptation of the gold to the bottom of the cavity, 
than by placing the ends of the blocks down upon an 
uneven surface. After the gold is all introduced, a 
small-pointed plugger must be passed all over the 
surface, to consolidate the protruding portions and 
form a surface to the filling. These protruding por- 
tions should be sufficient to make the surface perfectly 
flush with the border of the cavity ; for a depression 
here is fatal to a complete finish. After the surface 
is condensed with the fine and large points, it may 
be rubbed down with an instrument serrated upon 
the side, and afterward with the coarse file, and then 
with the fine, etc. 



166 TILLING TEETH. 

Dr. Badger describes a method of filling a small 
cavity on the posterior proximal portion of a second 
molar, the third molar gone. The cavity is formed 
with a bur drill. A cylinder is then formed in the 
usual manner, and forced through a series of holes in 
a drawplate, down to the size of the bur with which 
the cavity is formed. The block is thus rendered 
quite dense. The cavity is then dried, and the block 
forced into it, which it exactly fits, protruding a little 
from the orifice. This block is pierced in the center 
with a sharp instrument, and a small dense roll forced 
into it ; and all is then condensed and finished in the 
usual manner. 

Pellets. — Pellets made by rolling fragments or 
pieces of foil between the thumb and fingers, are used 
by some operators, and with them they profess to 
make as good filling as by any other method. They 
are made of various sizes, and packed into the cavity 
with sharp-pointed or serrate-pointed instruments. 
The pieces may thus be very solidly worked to- 
gether, and a good filling made, provided the pellets 
are not too large ; they should be small enough to 
permit the point or points to work through them into 
the preceding portions. Some operators use pellets 
and crystal gold together. This may do very well, 
if the adhesive property of the gold is employed; but 
in that case, either form of the material would answer 



CYLINDER OR BLOCK FILLING. 167 

alone. There cannot be as much gold put in by 
pellets as by blocks or cylinders well adjusted. 

Adhesive Foil. — By this we understand that condi- 
tion of gold foil in which the leaves unite readily and 
firmly together. This property of cohesion is pos- 
sessed, in the greatest degree, by properly manufac- 
tured foil, immediately after annealing. Not that 
annealing imparts any new property to the gold, but 
it removes obstacles to the manifestation of a principle 
possessed by all gold under favorable circumstances. 
It is now about twelve years since this property was 
first employed in gold foil for filling teeth. To Dr. 
R. Arthur is due the credit of first directing the 
attention of the profession to it. He not only did 
this, but he entered most fully into the details of the 
manipulations, instruments, etc., pertaining to this 
mode of operation. Almost all recently prepared 
gold foil possesses this property to a greater or less 
degree ; there are methods of preparing it, however, 
by which it possesses it most fully ; all recently 
annealed foil is adhesive. If the foil is adhesive 
when we wish to use it, nothing further is required 
in the way of preparation. But if it is not adhesive 
— as almost all foil is not, especially if it has been 
exposed to the influence of the atmosphere — it will 
require to be made so by some process : there are two. 
either of which will perfectly accomplish the object, 



168 FILLING TEETH. 

The one most frequently employed, is that of heat- 
ing the gold, either in the sheet, in the roll, or in 
fragments, over the flame of a spirit-lamp, almost or 
quite to a red heat ; if in the sheet, it should be laid 
upon a piece of wire gauze, and passed over the flame 
of the lamp for a moment or two ; if in the roll, it 
may be taken in the center with fine pliers and 
passed rapidly through the flame ; if in small frag- 
ments or pellets, placed upon a piece of charcoal and 
a light flame thrown upon them with a blowpipe. 
The other method is that adopted by Dr, Coates. 
Into a little platinum pan, large enough to hold an 
unfolded sheet of foil, are put one or two gills of rain 
water, to which are added about forty drops of sul- 
phuric acid ; and in this liquid the foil is boiled a 
few moments over the flame of a spirit-lamp. The 
acid removes all foreign substances from the surface 
of the gold. Remove it from the boiling liquid, and 
in a moment it is dry and ready for use, and will be 
most thoroughly adhesive. 

There are different methods of using gold in this 
condition ; but in general the cavity should be formed 
about as for the other methods of filling, except that 
to retain the first piece, there should be two or three 
small pits or holes made for retaining points in the 
most available position. The first portion of gold 
should be a little pellet ; this forced into these re- 



CYLINDER OR BLOCK FILLING. 169 

taining points, serves as a foundation for the remain- 
ing portion of the filling. Dr. Arthur's method is, 
then, to tear off fragments from the sheet, and pass it 
into the cavity without folding up, and condense it 
with an instrument of fine serrated point, so that it not 
only unites by cohesion, but it is worked into the 
surface of the preceding portion of gold ; and in this 
manner portion after portion is introduced and con- 
densed, until the cavity is full. The filling may be 
commenced in any part of the cavity that is most 
convenient ; in many, as in crown cavities of the 
molars, at the bottom, and filled to the orifice. In 
putting in the gold, it should, during its introduction, 
be kept fuller about the walls of the cavity than in 
the center; by this means the adaptation will be 
most perfect to the walls, and there will be no liabil- 
ity of clogging up the center. The gold may thus be 
built up to any desired extent if the filling is kept 
dry ; moisture is fatal to its adhesiveness. 

Others use the adhesive gold in a different manner. 
To Dr. Blakesley belongs the honor of first detailing 
the following plan : The sheet of gold may be folded 
or not at the pleasure of the operator, and then each 
sheet cut into from two to six strips, and these formed 
into a loose roll between the thumb and fingers. It 
may now be passed rapidly through the flame of a 
spirit-lamp to remove any foreign substance that may 



170 FILLING TEETH. 

be upon it ; when it is cut into little blocks or pellets 
of various sizes ; these to be regulated by the size of 
the roll and the amount cut off. For the introduction 
of the gold thus prepared, about three sizes of instru- 
ments are required, those having fine serrated points 
being preferable. As to the sizes of these points, 
Dr. Blakesley remarks, "they should just enter, 
respectively, Nos. 22, 24, and 26 of the wire-gauge." 
A larger than either of these, however, is desirable 
for many cases. As before, the filling may be com- 
menced at the bottom of a cavity or at one side, if 
desirable, with a pellet sufficiently large to be set 
firmly into the retaining points. Then take up the 
small pellets or blocks upon the point of the plugging 
instrument, and place them exactly in the desired 
position, and consolidate them thoroughly, building 
up next to the Avail all around higher than the center 
with the smaller pieces, filling up the little corners 
and interstices ; for which manipulation the smaller 
points will be required. The gold is then packed in 
till the cavity is full, when it is finished as usual. 
Another method is to tear off fragments from the 
sheet, and roll these up into round pellets, and fill 
with these, with the same instruments and upon the 
same principle as above described. But by this 
method it is difficult to make a perfect filling; the gold 
is liable to clog in the cavity, and fail in adaptation. 



THE MALLET. 171 

Adhesive gold must be consolidated as it is intro- 
duced ; for if a cavity is full, it is very difficult then 
to condense it more, even though the consolidation is 
but partial ; and the same is true to some extent of 
non-adhesive foil. 

THE MALLET. 

Within the last seven years quite a change has 
been effected in the theory and practice of consolida- 
ting gold in filling teeth. Prior to this period it was 
accomplished entirely by the pressure or force exerted 
by the hand. There was very considerable diversity 
of opinion as to the best mode of this manipulation. 
Some maintaining that great force is always required 
to make a filling sufficiently dense ; assuming that it 
is better to use comparatively large points, great 
pressure and rapid execution, thus securing the ut- 
most economy of time, both to the operator and 
patient. Others entertain the opinion that with 
smaller points, less pressure and more time, a more 
definite and. satisfactory result is attained. 

Notwithstanding the diversity of opinion and prac- 
tice upon this subject, we would suggest that young 
operators, at least should bear in mind, that in so 
important a matter as filling teeth, efficiency should 
never be sacrificed to rapidity. 



172 FILLING TEETH. 

About the year 1861, condensing gold, in filling 
teeth, by the use of the mallet was introduced to the 
profession by Dr. W. H. Atkinson. This method is 
especially applicable and effective for the condensation 
of adhesive gold, and indeed, gold in any form when 
the aim is to condense each portion as it is introduced. 
A more thorough condensation is made by the use of 
the mallet than is possible by the hand alone ; greater 
precision of manipulation is attainable ; it is easier 
for the operator ; and usually less unpleasant to the 
patient. 

The character of the results in the use of this 
instrument depends much upon the skill of the assis- 
tant. It requires time, care and patience to famil- 
iarize the assistant with the use of the instrument. 
The plugger should be held firmly in position by the 
operator, and receive the stroke squarely upon the 
end ; it should be a sharp springing tap. "Very much 
depends upon the character of the blow; a dead 
heavy stroke will not unite the gold as it should be. 
It is important that the assistant be able to follow 
the indications of the operator, without loss of time. 
Many assistants are disposed to give time strokes 
instead of following indications; which are not ad- 
missible except in very simple cases. 

In order to avoid the employment of an assistant, 
and to place the strokes of the instrument more under 



THE MALLET. 173 

the control of the operator, various forms of automatic 
mallet pluggers have been invented and constructed. 
Two or three principles embrace the whole, though 
perhaps twenty different forms have been made. Those 
operated by the action of spiral springs have been the 
more common ; the objection to almost all of these is, 
that the stroke lacks the desired elasticity. This 
class of instruments is represented in general aspect, 
by Fig. 44. 

Fig. 44. 






This instrument was invented by Dr. I. A. Sal- 
mon, and is one of the best of this form ; and operates 
well in the hands of those who become familiar 
with it. 

Another form of mallet plugger is represented in 
Fig. 45, in which the blow is communicated by a 
spring of another form, and of such an arrangement 
as to give a springing stroke. This instrument was in- 
vented and made by Dr. W. Gr. Redman. It would be 
objectionable in the hands of some, because of its size, 
weight and form : use and custom will remove great 
apparent, and even real, difficulties. 

Both of these instruments are less under the control 
of the operator, in respect to the force of the blow, 



174 



FILLING TEETH. 



than 



Fig. 45. 



they should be. It is true that in both, the 

force can be regulated 
to the most minute de- 
gree, between a very 
light and a very strong 
stroke ; it cannot be 
done however, without 
giving special attention 
to that particular; which necessitates an 
arrest of the operation of the instrument. 

An instrument is made by Dr. S. B. Pal- 
mer, in which the force of the blow is placed 
completely under the control of the opera- 
tor, while it is being used. The operation 
of this instrument is perhaps less objection- 
able, in respect to the character of the 
stroke, and its control by the operator, than 
any other as yet employed. Any of these 
instruments are valuable in the hands of 
those who become familiar with their use. 




CRYSTAL OR SPONGE GOLD. 



The form of the cavity for crystal gold filling, 
should be much the same as that described for other 
fillings, except that the same care is not necessary for 
special retaining points; for the first portion of good 



CRYSTAL OR SPONGE GOLD. 175 

crystal gold that is introduced into the cavity, will 
attach to the walls of a cavity without any such special 
retaining points : such a form should be given, however, 
as to secure the first piece firmly in place. The gold 
should be cut or broken into pieces corresponding in 
size to the cavity, so that they will enter freely 
into it. 

The filling may be commenced upon the bottom of 
the cavity, or upon one of its sides ; such a point 
always being selected as will most effectually retain 
the gold in place. The pluggers should be of various 
sizes — the first one as large as can be used in 
the cavity, and smaller ones for condensing more 
thoroughly; and all should be serrated with from two 
to six sharp points, usually four. The blocks may be 
taken up on the point of the plugger, or perhaps bet- 
ter with the pliers, and passed to the proper position 
in the cavity, and there condensed. The sharp, ser- 
rated point leaves the surface in good condition for 
the reception of the next piece. The gold should be 
packed to the walls of the cavity a little in advance 
of the center, so that its adaptation may be more 
complete. In this manner, the filling is built up as 
much as is desirable, if it is kept dry — and unless 
it is, cohesion is very much diminished, or lost 
altogether. 

The gold, after it is cut up, is passed through the 



176 FILLING TEETH. 

flame of a spirit lamp to anneal it, and dispel all 
foreign substances; it should in no case be brought 
above a perceptible red heat; and usually not to that 
point; it should be done carefully, so as not to fuse 
any of the particles, as that would impair their facility 
of cohesion in this process: small portions are often 
required to fill up small interstices, or notches. 

In crown cavities, the filling should begin at the 
bottom; in proximal cavities, at the cervical wall. 
By introducing the gold in this manner, the pressure 
is made on a line with the axis of the tooth ; which 
is an important consideration. The surface of the filling 
should be made to conform to that of the lost portion of 
the tooth; this can always be done except where the 
tooth is largely broken away, and even then very 
much may be accomplished, in many cases, to restore 
the lost form; that will depend, however, upon the 
method of using the gold. In crown fillings of the 
molars and bicuspids, the antagonism of the teeth 
must be regarded ; they should be formed for the 
reception of the cusps of the opposing tooth. Proxi- 
mal fillings should usually be convex; yet many good 
fillings of this class are effected with a surface per- 
fectly plain with the borders of the cavity. The 
borders of the filling, however, are better protected 
when it is somewhat convex. 

Crystal gold, of perfect character, presents to the 



CRYSTAL OR SPONGE GOLD. 177 

walls of the cavity a surface better calculated to be 
retained, than foil in any of its forms; though adhe- 
sive foil possesses this advantage to a greater extent 
than foil in any other condition. The points and 
edges of the crystals are brought in contact with the 
walls, and take a firmer hold upon the dentine. 

In forming crystal gold into a solid mass, two 
principles are operative : cohesion acts upon it as 
potentially as upon gold in any other form, and, in 
addition, there is the interlacing, or locking, of the 
crystals with one another ; so that a more perfect 
union of the different portions of which a filling is 
composed, is obtained with crystal gold than with 
foil. Yet good adhesive foil, when thoroughly 
worked in, attains almost the same condition. With 
perfect crystal gold, however, some advantages may 
be secured, that can not be had with foil. The gold 
will be retained in a cavity that will not retain a foil 
filling; it is more easily formed into a coherent mass; 
it can be built out with more ease ; cavities can be 
filled with it that can not be rilled with foil at all ; 
and a filling of it is susceptible of a better finish, with 
the same labor, than a filling of foil. 

It is important to keep the gold perfectly free from 
moisture, while being introduced and consolidated ; 
for moisture instantly destroys its cohesive property. 
And the more complete the exclusion of moisture 



178 



FILLING TEETH. 



from the cavity, during the process, the better for 
the success of the operation. The surface of every 
filling should be consolidated for finishing, before 
it is allowed to become moist; for, if it becomes 
saturated with moisture before consolidation, it is 
impossible to make a perfect finish. There should 
always be gold enough superadded to insure this; 
and the consolidation of the surface should be effected 
with a burnisher of the proper form, used with the 
mallet, consolidating the entire surface as thoroughly 

Fig. 46. 



€S c> 



i u 



j> j> 



)) 




and smoothly as possible, exercising great care about 
the borders of the filling. Fig. 46 represents the 
forms of the burnishers suitable for almost all cases. 



FINISHING FILLINGS. 179 



FINISHING FILLINGS. 



The method of finishing a filling, and the manipu- 
lation required, will depend somewhat on its locality. 
When the filling has been thoroughly consolidated 
over all the surface, and especially all round its 
border, the file should be applied to dress off any 
projecting portion, and render it smooth. In consoli- 
dating the surface, an instrument should be used that 
would not pit it, and the file should remove all inden- 
tations. The work of the file, however, should be 
but partially performed at first, and the surface 
burnished again. To obtain the most perfect finish, 
the surface should be brought to a uniform consist- 
ence ; and this condition can not be reached by the 
use of sharp-pointed instruments, nor fully by that of 
the blunt plugger at the first effort, but by the alter- 
nate use of the file, the blunt condenser, and the 
burnisher. A coarse file should be employed in this 
part of the process ; but when the filling is dressed 
sufficiently, and in good condition, the fine file should 
be used, alternately with the burnisher, till a perfectly 
uniform surface is obtained. In all cases, after the 
file has been applied, the plug should be washed off 
with a brush, to remove all detached pieces of gold, 
before the burnisher is put upon it ; and after the 



180 FILLING TEETH. 

fine file and burnisher, the Scotch- or Arkansas-stone. 
or corundum slips of the proper form, used with the 
port-polisher, or very fine pumice should be employed 
to remove the filemarks. The pumice may be applied 
with water on a strip of chamois skin, a piece of 
linen tape, or a stick of soft wood — the latter being 
the most convenient, as it can be used with one hand 
and shaped to suit any place or position. 

After the stone or the pumice has accomplished its 
work, and the filling has been thoroughly washed, a 
fine burnisher, with a solution of castile soap, is em- 
ployed to give the finish. The burnisher should be 
of the best cast steel, and of high temper and fine 
polish. Considerable skill is requisite to give the best 
effect with the burnisher; it should pass smoothly 
and gently over the surface, throughout its whole 
extent, and in parallel lines, with a pressure neither 
too light nor too heavy. It should also be applied 
very thoroughly upon any portion of the tooth about 
the border of the filling, that may have been cut by 
the file or any other instrument. Indeed, quite as 
much, if not more, care should be exercised upon 
this as upon the plug itself: it should be polished as 
smooth as the enamel, if possible; for the more nearly 
perfect it is in this respect, the better will it resist 
the action of the deleterious agents. 

This method of finishing gives to the filling a per- 



FINISHING FILLINGS. 181 

feet metallic luster; which, under some circumstances, 
is objectionable. Two other methods are in use : 
after the burnisher has been applied, as above, the 
buff or tape, with rouge, may be employed, by passing 
it rapidly over the filling, till the metallic luster is 

l destroyed, or deadened, so as not to reflect the light 
as before, thus leaving a very desirable finish ; and 
the other method is, to stipple over the surface of the 
burnished filling with the end of a piece of hard 
wood — sandal wood is recommended — charged with 
finely pulverized pumice. This gives a beautiful, 
velvet-like surface, and is fine for fillings in the an- 

* terior portion of the mouth, where they are exposed 
to view. Rotten-stone, applied either with the buff 
or with hard wood, imparts a finish which, though a 
little different, is equal to any of the others. 

For finishing, some operators prefer to cut and 
polish, instead of filing and burnishing. But neither 
so good nor so fine a finish can be effected in this 
way, and it is probable that economy of time and 

. labor, especially the latter, suggested the method. 
In all cases, the filling should have a distinct and 
definite margin: the gold should be trimmed off quite 
up to the border of the cavity, by passing round it a 
small, sharp instrument, so as to detect and pare 
down any portion that might overlap the tooth. 
For, if overlapping portions are permitted to remain, 



182 FILLING TEETH. 

foreign substances will lodge beneath, and induce 
decay. Neglect in this particular has occasioned the 
loss of thousands of teeth that otherwise might have 
been saved. This direction does not apply to those 
cases elsewhere mentioned, in which it is recom- 
mended to form a thick firm overlapping portion, for 
the protection of a thin friable border. 

The subject of finishing is almost entirely over- 
looked by very many operators ; but by the neat and 
skillful it is esteemed of sufficient importance to 
demand as great labor and pains as any other part 
of the operation. 



CHAPTER VII. 

CLASSIFICATION OF DECAYED CAVITIES. 

The following classification of decayed cavities in 
the teeth, though from the very nature of the subject 
imperfect, will be found sufficiently accurate for the 
^purposes of the dental student and the practitioner. 
It is based primarily on the position of the cavities, 
and secondarily on the extent of the decay ; the classes 
having reference to the former, and the modifications 
to the latter. The classes are numbered according to 
the accessibility of the cavities, beginning with those 
most easily approached and operated upon ; and the 
modifications according to the extent of the decay, 
beginning with the smallest and simplest in form. 

First Class. — Central crown cavities in the molars 
and bicuspids. 

1st Mod. — Extension of the decay along one or 
more fissures or depressions. 

2d Mod. — Two decays in close proximity on the 
same crown, which may be formed into one cavity 
for filling. 

Second Class. — Cavities in the buccal and palatal 



184 CLASSIFICATION OF DECAYED CAVITIES. 

surfaces of the molars and bicuspids, and in the labial 
and palatal surfaces of the canines and incisors. 

1st Mod. — Extension of the decay beneath the 
margin of the gums. 

2d Mod. — Extension of the decay so as to involve 
a portion of the crown surface. 

Third Class. — Anterior proximal cavities of the 
bicuspids and molars. 

1st Mod. — Extension of the decay toward the neck 
of the tooth, beyond the termination of the enamel. 

2d Mod. — Extension of the decay so as to involve 
a portion of the grinding or crown surface. 

Fourth Class. — Proximal cavities of the incisors 
and canines. 

1st Mod. — Palatal wall of the cavity broken away. 

2d Mod. — Labial wall broken away. 

3d Mod. — The cavity at the point of the tooth, ter- 
minating at the surface. 

Ath Mod. — The borders of the cavity very thin, and 
the lateral walls inclining to the center. 

Fifth Class — Posterior proximal cavities of the 
molars and bicuspids. 

Modifications same as those of third class. 

Modifications common to all the classes : — 1st. Su- 
perficial cavity and a large orifice. 2d. Deep cavity 
and a small orifice. 

Modification common to classes three, four, and 



FILLING BY CLASSES AND MODIFICATIONS. 185 

five : — Transverse extension of the decay round one 
or more angles of the tooth, under the termination of 
the enamel. 



FILLING BY CLASSES AND MODIFICATIONS. 

First Class. — Central cavities of the molars and 
bicuspids. These decays always begin in the depres- 
sions on the masticatory surfaces, which are vulner- 
able points, the enamel-membrane folding together 
here, and often being imperfectly united, so that an 
opening is left through it to the dentine: besides, 
these indentations afford lodgment for foreign sub- 
stances, which may be forced into them in the process 
of mastication, and there retained, till, becoming 
vitiated, they produce decay. Examine carefully the 
extent and the nature of the decay, and the form of 
the cavity, which, of course greatly varies. In some 
cases, the cavity is found with a small diameter and 
a comparatively great depth, the diameter at the 
orifice being the same as within; in others, with a di- 
ameter larger at the orifice — as occurs in cases in which 
a considerable portion of the enamel at the depres- 
sions on the crown is imperfect. In the majority of 
instances, however, the diameter of the cavity is 
much larger within than at the orifice. Sometimes 
the decay is found to burrow directly beneath the 



186 CLASSIFICATION OF DECAYED CAVITIES. 

enamel more rapidly than in any other direction; as 
where there is an imperfect union between the enamel 
and the dentine. In other instances, the cavity seems 
to expand uniformly as it extends into the tooth. 

The manner of opening up and preparing the 
cavity for filling, will depend somewhat on the form 
given to it by the decay. If it is larger at the orifice 
than within, there will be little or no cutting of the 
cavity about the orifice necessary, except to make it 
even and smooth; and its preparation will consist in 
an entire removal of the decay, and such a shaping of 
the interior as will insure a retention of the filling. 
This may be effected either by enlarging the cavity 
within, till its walls are parallel with each other, or, 
if these are left converging, by forming pits or grooves 
upon them at proper points. Converging walls pre- 
sent one or two advantages, which will be hereafter 
considered. Usually, where the decay has formed a 
cavity of nearly uniform diameter from the orifice to 
the bottom, about all the preparation for filling that 
is requisite, is a thorough removal of the decay. In 
cases in which the decay burrows under the enamel, 
the projecting portions are to be cut down, either with 
a bur drill, or, what is generally better, a heavy 
cutting instrument. In most instances, it is best to 
cut away the enamel as far as the decay has extended 
beneath it, since it is difficult to make a perfect filling 



FILLING BY CLASSES AND MODIFICATIONS. 187 

under a projecting portion. In some cases, however, 
where the enamel is thick and firm, it is admissible to 
leave a slight projection, so as to form, as it were, a 
shallow groove. 

The walls of these cavities will be of various in- 
clinations. If they converge, pits or grooves may be 
required upon them for retaining points, especially if 
the enamel be cut away at the orifice to the solid 
dentine. If, however, the walls, or two opposite 
walls, are parallel, or but slightly divergent, these 
special retaining points will not be necessary, except 
for the reception of the first pieces of gold. Small 
cavities of this class may be opened up and formed 
principally with the bur drill ; but in large cavities, 
this instrument is not available. Thus the orifices of 
the small cavities would be round, while those of the 
large would be of various forms, determined by the 
direction of the decay; as, round, square, triangular, 
elliptical, parallelogramic. Cavities should not be 
formed much larger within than at their orifices, unless 
the filling can be consolidated so perfectly that it will 
not yield in the least u.nder the greatest pressure of 
mastication ; for, if there is any yielding in such cases, 
under direct pressure, the filling being forced into a 
larger part of the cavity, withdraws from the walls, 
leaving an interval coextensive with the depression 
it has undergone ; and thus fluids would be admitted 



188 CLASSIFICATION OF DECAYED CAVITIES. 

between the walls and the filling, and the purpose for 
which this was inserted would be entirely defeated. 

Many operators ream the orifices of all the small 
and medium-sized cavities of this class, in order 
thereby to make a better finish to the border of the 
rilling. Some operators prefer in all cases to remove 
the angle formed by the wall of the cavity and the 
surface of the tooth about the orifice, giving a rounded 
form to the border of the orifice, the object being to 
avoid fracturing or comminuting the edge of the 
enamel or dentine about the cavity. All acute angles 
in these cavities, especially if they extend to the 
orifice, should be obliterated, since it is impossible to fill 
them perfectly. This obliteration can be effected with 
a miniature chisel, or with the appropriate excavator. 

After the formation of the cavity, the next particu- 
lar is so to arrange as entirely to exclude moisture, 
whether from the saliva or from the breath. Ordi- 
narily, in operations on the superior teeth, the follow- 
ing arrangement will be sufficient for the purpose : 
Wipe dry the mucous membrane about the mouth of 
the duct of Steno ; lay directly upon this a piece of 
heavy blotting paper, or a roll of bibulous paper; then 
take a napkin folded cornerwise, place the end of it 
upon the paper, between the cheek and the gum, 
passing it back of the tooth to be operated upon, 
along the palatal surfaces of the teeth and the gums 



FILLING BY CLASSES AND MODIFICATIONS. 189 

to the anterior part of the mouth, and letting a fold 
of it extend down from this, and out over the inferior 
front teeth and the lip, so as to protect the tooth 
from the breath, and catch any fragments of gold that 
may drop from the instrument. The napkin and 
paper thus arranged, are to be kept in their place by 
the fingers of the left hand of the operator; and, if 
the mouth of the duct is kept closed by the paper, a 
complete exclusion of moisture is secured. In some 
cases, pressure of the ringers on the napkin over the 
duct is necessary; in others, the paper adheres to the 
mucous membrane, and effectually prevents the egress 
of saliva. The cavity should now be dried by the 
method heretofore described, and it is ready for the 
filling. 

In operations on inferior teeth, more care is requisite 
to protect them from moisture. Bibulous paper should 
be packed in on the mouths of the sublingual and 
submaxillary ducts, and a roll of paper placed between 
the cheeks and the teeth. A larger roll of napkin, 
too, than that used for the upper teeth, should be 
disposed in the same manner as above suggested, and 
held in place by the patient with a speculum (Fig. 
47), or by the fingers of the operator. 

Cases are frequently presented in which the flow 
of saliva is so abundant, and of such a peculiar char- 
acter, as to render it difficult to protect the teeth from 



190 



CLASSIFICATION OF DECAYED CAVITIES. 



its contact during an operation, and especially the 
inferior, teeth. 

Various appliances and methods have been devised 



Fig. 47. 




and employed for overcoming this difficulty. The 
idea was several years ago conceived, of removing the 
saliva as it accumulates; and hence the construction 
and employment of the saliva pump represented in 
Fig. 48. This instrument, though very good in its 

Fig. 48. 




operation and accomplishing much in the right direct- 
ion, does not completely fulfill the requirements. 



FILLING BY CLASSES AND MODIFICATIONS. 191 

An instrument recently brought to the notice of the 
profession, by Dr. W. H. Dibble, called "Dibble's 
Saliva Pump," performs the work of both the saliva 
pump and speculum, or tongue holder. As a saliva 
pump it is much superior to the instrument repre- 
sented in Fig. 48, which is in common use. 

It is operated by the patient, and removes the 
saliva immediately after it enters the mouth, and 
may be in constant action, without the slightest in- 
terruption of the operation of filling; the saliva passes 
into a reservoir, and is perfectly enclosed, till the 
operation, however protracted, is completed. 

That part of the instrument designed to hold the 
tongue, and the buccal surface, from the tooth to be 
operated upon, and to hold the jaws apart, is of a 
very excellent form, and accomplishes its work well. 
It is in three parts, one adapted to each side of the 
mouth — in these the saliva is taken up by the instru- 
ment opposite the lingual surface of the second inferior 
molar — and one for the front, with a compressor 
passing on -to the tongue and holding it firmly down, 
and the pump-tube, taking the saliva from the immedi- 
ate vicinity of the sublingual ducts. 

This latter part of the instrument is the device of 
Dr. B. F. Arrjngton. The instrument is well repre- 
sented in Fig. 49. 

In the use of the common speculum, much difficulty 



192 



CLASSIFICATION OF DECAYED CAVITIES. 



Fie. 49. 




is often experienced by 
the patient relaxing the 
hold, or compression, or 
moving it from one side 
to the other, on account of 
fatigue of the parts upon 
which it bears. This fact 
induced the idea, and sub- 
sequently the production 
of the Tongue Compressor 
or Clamp Speculum. This 
instrument in many cases 
serves a very valuable 
purpose, holding the ton- 
gue in a fixed position; 
and in connection with 
it, by the proper adjust- 
ment of pads of bibulous 
or blotting paper upon 
and beneath the tongue, 
entirely arresting the dis- 
charge of saliva from the 
sublingual and submaxil- 
lary ducts. This instru- 
ment is represented in 
Fig. 50. 
Many experiments have 



FILLING BY CLASSES AND MODIFICATIONS. 



193 



been made with the view of excluding the saliva by 
building a fortification of some proper material about 

Fig. 50. 




the tooth. But while in some cases this method will 
accomplish the desired result, in the greater propor- 
tion of instances it will prove a failure. 

Afar better and more efficient method — one recently 
adopted — is the use of fine rubber cloth, forming with 
it a coffer-dam ; which is done by making a round hole, 
or series of holes, from two to four lines in diameter 
through a piece of the cloth, which should be from four 
to six inches square ; draw this over the tooth to be pro- 
tected and those immediately adjoining; it should be 
manipulated well up on the neck of the tooth, even 
beneath the free margin of the gum; if a proper adjust- 
ment is made, the saliva will be entirely excluded, and 
for afar longer time than by any other method now used. 



194 



CLASSIFICATION OF DECAYED CAVITIES. 



It is often the case, that the finger is too short to 
reach a desired point, to hold down a napkin, or 
paper, or hold away the soft parts, or so large as to 
fill the space inconveniently, obstructing the view or 
the operation. To overcome both of these difficulties 
an extension thimble is used; it may be made of silver 
or rubber, though better of the former. In addition 
to the uses mentioned it may by having a fine steel 
point, be used to aid in introducing fillings. (Fig. 51.) 

Fia 51. 




Various appliances have been used for holding 
away the cheek, keeping down the tongue, and re- 



Fie. 52. 




taining the jaws apart. A good instrument, however, 
for this purpose is shown in Fig. 52. 



FILLING BY CLASSES AND MODIFICATIONS. 195 

Filling with Foil. — If non-adhesive gold is employed, 
it should be formed into blocks, by cutting from four 
to eight thicknesses into strips one fourth wider than 
the cavity is deep, and rolling them on a broach suit- 
able for the purpose, into cylindrical blocks corres- 
ponding in size with the cavity to be filled, and 
varying not only in size, but in form and density. 
The blocks first to be introduced should be largest, 
followed by those dimishing in size, the last portions 
being small, dense, conical rolls. Where there is an 
inward or outward inclination of the walls of the 
cavity, the first blocks should be cone-shaped. For 
introducing the blocks, the plugging pliers will be 
required. The first block is taken up with this in- 
strument, and placed against the posterior wall of the 
cavity with one end on the bottom and the other pro- 
truding from the orifice, and there compressed firmly 
to its place with the appropriate condensing instru- 
ment; and, unless there is some special retaining 
point, it may be necessary to hold it in its position 
with a second instrument, till the next portion is 
added. As the successive blocks are introduced, each 
is to be thoroughly consolidated, so as to be immov- 
able. The filling is to proceed from the posterior walls 
to the center. After the cavity has thus been rilled to 
the center, commence in the same manner at the an- 
terior wall, rilling from thence toward the center, and 



196 CLASSIFICATION OF DECAYED CAVITIES. 

condensing the last blocks by forcing in at their side 
a small sharp-pointed instrument: the final portion 
introduced will be the small, dense, conical roll already 
mentioned. The gold being all introduced, a smooth- 
pointed instrument or burnisher condenses the project- 
ing portion of the filling till it is perfectly solid, when 
it is finished with a fiJe, stone and burnisher, in the 
manner already described. The particular shape of 
the surface of the filling will be suggested by the 
form of the antagonizing tooth. If there is nothing 
to prevent, the surface may be slightly convex; but 
if there are cusps striking upon the center of the 
crown, it should be concave. 

For dressing down the filling when a concave sur- 
face is required, the instrument represented in Fig. 53 
is very efficient. It consists of a spherical file, or bur, 

Fig. 53. 



finely cut, and on a proper shaft or handle ; and may 
be used in the manner of the ordinary bur drill. A 
variety of sizes and forms should be at hand, in order 
to operate properly upon fillings of various sizes. 

Adhesive Foil. — For filling these cavities with adhe- 
sive foil, definite retaining points should be formed in 
them, or the bottom of the cavity of such a form as to 
retain firmly in position the first pieces of gold intro- 



FILLING BY CLASSES AND MODIFICATIONS. 197 

duced. The gold, prepared in the manner already de- 
scribed, is taken up with a serrate-pointed plugger or 
plugging pliers, introduced into the retaining point or 
points, and there fixed; it is then built across from one 
to the other, and over the floor of the cavity, till this 
is completely covered, and then up from the bottom to 
the orifice. When a portion of gold is taken on the 
point of the instrument, the precise spot at which to 
deposit it should be selected, and there it should be 
placed, and, by the first pressure of the instrument, 
fixed immovably; a few subsequent strokes of the 
instrument close about the first point of attachment, 
will be required. These strokes should be close, 
because if the instrument is lifted up and pressed 
upon the piece at a distance from the first point 
of contact, the attachment is liable to be broken. 
The character of the gold, and the condition of the 
receiving surface will govern to some extent the pre- 
cise method of manipulation. Very much depends 
upon keeping the surface in a good condition for the 
reception of the gold to be added. The best receiving 
surface is obtained by having the condensing instru- 
ment sharp and in good condition, and then in using 
it, let there be a little space between its impressions — 
the surface not stamped completely over by the con- 
densing instrument. In constructing the filling, we 
consider it preferable to keep it built up a little higher 



198 CLASSIFICATION OF DECAYED CAVITIES. 

all around next the walls than at the center, for the 
reason that a more complete adaptation of the gold 
can thus be made, than by any other plan. Some, 
however, advocate the opposite practice ; that is, of 
keeping the rilling higher in the center than at the 
walls, and thus forming an angular space into which 
to crowd the gold ; because the gold is thus kept in 
more thorough contact with the walls of the cavity; 
and it is objected that, to add and consolidate the 
gold to the center, while the edges are left higher, 
tends to draw them from the walls. This objection, 
however, has no force, if the gold is thoroughly con- 
solidated as it is introduced. 

The cavity is thus filled up, consolidated, and fin- 
ished in the usual manner. In adding the last por- 
tions of gold, great care should be taken to make a 
perfect border to the filling. Crystal gold may be 
very advantageously used as a foundation for adhe- 
sive foil fillings, as it will retain its position perfectly 
in a cavity, where foil would not. 

Crystal Gold. — The method of filling this class of 
cavities with crystal gold is very simple. The mate- 
rial should be annealed just before its use, and then 
cut or broken into blocks corresponding with the size 
of the cavity to be filled : they may be used as large 
as will freely enter the cavity; many small pieces 
will be required to fill up interstices or angles. The 



FILLING BY CLASSES AND MODIFICATIONS. 199 

filling may be commenced at the bottom of the cavity, 
and built up from that to the orifice, the same plan 
being followed in adapting it to the walls as with ad- 
hesive foil, the pieces being passed into the cavity 
with either the plugging pliers, or a condensing in- 
strument. Each piece should be well consolidated 
before another is added. For condensing the filling 
next to the walls, a small wedge-shaped instrument is 
valuable. In all cases where there is a divergence of 
the anterior wall, much care is required in order to 
make a perfect filling; and too much care can not be 
exercised in perfecting the filling round the border of 
the cavity. In condensing adhesive foil or crystal 
gold, the force may be applied almost exclusively in 
a line with the axis of the tooth; and this is always 
preferable to lateral pressure. 

1st Mod. — Extension of decay along one or more 
crown fissures. In a case of this kind, the central 
cavity is first to be opened and excavated, according 
to the principles already announced. Decay in the 
fissures is in some cases an extension of this central 
decay, and at the point of its termination there will 
be found an acute angle ; but in others, it will be the 
effect of an equal attack all along the fissure, or of 
an extension from some other point than the central 
cavity. This modification of decay may terminate 
either in an acute angle, or in an expansion. 



200 CLASSIFICATION OF DECAYED CAVITIES. 

These decayed fissures should be opened up by 
cutting away any projecting portion of enamel, and 
the cavities formed with a small chisel-shaped instru- 
ment, beginning at the juncture of the fissure with 
the main cavity, and cutting down to the bottom of 
the decay in the manner of a mortise, thus cutting 
out the entire fissure and the acute angle at its ter- 
mination — the latter an important consideration. In 
case there is a very considerable expansion of decay 
at the termination of the fissure, the* bur drill may be 
introduced into it, and the rest of the fissure cut out, 
as the form of the cavity may indicate. 

If blocks are used to fill these cavities, they should 
be set in and compressed against the end of the fis- 
sure, protruding from it sufficiently to admit of a 
proper finish; and block after block added, till the 
fissure is filled up to the main cavity. Where there 
are two or three of these decayed fissures in one 
tooth, it may be quite as much as can be done at 
one sitting, to fill them, the main cavity being left 
for another time. In such cases, the filling intro- 
duced at the first sitting, should then be consolidated 
and burnished, so that it may not absorb moisture till 
the main cavity is filled, as already described. Much 
care should be exercised to prevent the gold from 
overlapping the enamel at the sides of these fissures. 
In filling this modification with crystal gold or an- 



FILLING BY CLASSES AND MODIFICATIONS. 201 

nealed foil, it is better to begin at the bottom of the 
cavity and build up to the orifice, first completing the 
fissure, as we have already described, and afterward 
the main cavity. 

Id Mod. — Two cavities on the same crown in close 
proximity. The thickness of the portion of tooth in- 
tervening between two cavities on the grinding surface 
of the same crown is determined by the extent of the 
decay and by the form of the cavities; and these two 
conditions will suggest the method of operation. If 
this intervening portion is thin throughout, and devoid 
of vitality, it should be cut away, and the two cavities 
formed into one ; but if it is thick within, though it 
may be thin at the surface, the cavities should be 
filled separately. In some cases it is proper to leave 
a part of it standing, as a sort of ridge between the 
cavities, though not as a definite partition; in which 
case the filling would be begun as in two cavities, 
and finished as in one. In no case, however, when 
the tooth is living, should this intervening portion re- 
main, if its vitality is gone. The details of the pro- 
cess of filling crown cavities have already been indi- 
cated. 

Second Class. — Buccal and palatal cavities of the 
molars and bicuspids, and labial and palatal cavities 
of the canines and incisors. In the molars, this class 
of decay begins either at the margin of the gum, in 



202 CLASSIFICATION OF DECAYED CAVITIES. 

the form of a transverse groove, or along the vertical 
depression on the buccal surface of the tooth, or at its 
termination. These groove-like decays, extending 
along the side of the tooth at or near the margin of the 
gum, are ordinarily not very deep; but they burrow 
considerably under the enamel, particularly at the side 
next the grinding surface. In preparing these cavi- 
ties, the projecting portion of the enamel must be 
mostly cut away, leaving them but slightly larger 
within than at the orifice. These grooves, at their 
ends, are shallow; but in their preparation for filling; 
they should be cut as deep at the ends as elsewhere, 
and, when the main part of the cavity is comparatively 
shallow, deeper. Much difficulty is often experienced 
in protecting these cavities from moisture while being 
filled. The rubber coffer-dam when well applied ac- 
complishes the object better than any other appliance; 
it is in such cases invaluable. 

The method of introducing gold in the form of blocks 
into these cavities, is, to set in the first block at the 
posterior part of the cavity, and consolidate it, and so 
one block after another till the cavity is nearly full; 
and then proceed in like manner with the anterior end, 
back toward the middle, the blocks, of course, being 
permitted to protrude sufficiently for the purposes of 
a finish. For filling with crystal gold or adhesive foil, 
the method is, to form pits at the end of the groove, 



FILLING BY CLASSES AND MODIFICATIONS. 203 

into which the gold is consolidated, and built across 
from one to the other, and then up from the bottom 
to the orifice, when it is finished as usual. Care is 
requisite to prevent the gold from overlapping the 
tooth. Any projection of the filling, especially beyond 
the margin of the cervical wall of the cavity, is very 
objectionable; it would afford a lodgment for extrane- 
ous substances. The tendency of which is to produce 
irritation and decay. 

Cavities of this class, which are formed in the de- 
pressions of the buccal portions of the teeth, are more 
easily filled. Often a simple round cavity is formed, 
which may be Entirely prepared with a bur drill. The 
method of rilling these cavities will be readily inferred 
from the remarks before made. If, however, the decay 
extends along the depressions, making a groove-like 
cavity, this should be filled by commencing the intro- 
duction of the gold at that side of the cavity next the 
gum. 

1st Mod. — Decay at or near the neck of the tooth, 
and partially or wholly overlapped by the free border 
of the gum. In this modification the gum is a great 
obstacle to the various steps in the process of filling : 
it is liable to be wounded and to bleed at every touch; 
it exudes mucus constantly; and it conducts saliva to 
the parts with great facility. To obviate these diffi- 
culties, the gum must be removed somewhat From the 



204 CLASSIFICATION OF DECAYED CAVITIES. 

cavity before the filling is practicable. This removal 
of the free margin of the gum may be made either by 
cutting away; or by pressing away with pledgets of 
cotton or other appropriate substance placed in the 
cavity and projecting from it, so as to make pressure 
upon and absorption of, to a sufficient extent, the free 
margin of the gum, which will usually be accomplished 
in a day or two. The former method, however, 
accomplishes the object at once : some good hemo- 
static, as creosote and tannin, is all that is then 
necessary to render the filling immediately practica- 
ble. By means of this application the exudation 
is checked — which, where there is much mucus eli- 
minated, is an important item — and also such a 
surface is given to the part that it will not so readily 
conduct the saliva. It is, perhaps, preferable in 
many cases to cut away this free margin, so that 
it shall not be in contact with the filling after the 
operation is completed. 

After this preparation, the cavity is formed and 
filled as usual. The napkins and paper, if these are 
used, are to be placed in the precise position, and 
carefully retained there. Two or three thicknesses 
of paper should be laid on the gum up to the margin 
of the cavity, and kept there during the process of 
filling, so as to exclude all moisture. In filling cavi- 
ties of the buccal portions of the denies sapientice, 



FILLING BY CLASSES AND MODIFICATIONS. 205 

peculiar difficulties are met with: the decay is fre- 
quently found two-thirds covered by the gum;, the 
muscles of the cheek, thick and rigid, lie close against 
the side of the tooth; and, in most cases of this kind, 
the view, at best, is but partial. In operating upon 
these cavities, an instrument for holding out the cheek 
is required. 

Third Class. — Anterior proximal cavities of the 
molars and bicuspids. This class of cavities in teeth 
with short, broad crowns, takes place at their necks; 
but in those with long crowns, and with a diameter 
less at the neck than at the masticating surface, it 
begins at some distance from the neck, toward the 
crown surface, or at the first point of contact of the 
crowns. In almost all cases of proximal fillings sepa- 
ration of the teeth is required; the method and extent 
of this will be determined by circumstances. If all 
the neighboring teeth stand in contact, it cannot be 
easily accomplished by pressure ; in this respect, how- 
ever, there will be found a great variety; but, if a 
tooth has been extracted in the vicinity, or there are 
natural spaces between the others, it can be either in 
whole or in part. When, however, the teeth stand 
close together, they must in such case be separated 
chiefly with the chisel and file. If but one is decayed, 
the cutting should be exclusively from that. If two 
are alike affected on their proximal surfaces, it should 



206 CLASSIFICATION OF DECAYED CAVITIES. 

be mostly from the posterior surface of the anterior 
tooth. In regard to the form of the separation effected 
by cutting, the general practice formerly was to cut 
down the whole proximal side of the affected tooth, 
making between it and the adjoining one a V-shaped 
space, sufficient in extent to admit of free manipula- 
tion in all parts of the operation of filling. By thus 
cutting the teeth, the form is marred, and often to 
great disadvantage in use, as by it the masticating 
surface is lessened, and food being crowded into 
such a space produces very unpleasant pressure. In 
order to preserve the form and the greatest amount 
of masticating surface to the tooth, a preferable 
method is to cut a mortise down from the masticating 
surface to the cavity of decay, leaving the lingual and 
buccal sides of the tooth untouched, except, perhaps, 
a little dressing that may be rendered necessary by 
the thinness and roughness of the margins. This 
cutting should extend about as far toward the center 
of the tooth as the decay has penetrated, and be 
nearly as wide as the extent of the decay across the 
tooth. When it is necessary to cut from the whole 
proximal surface there should be no shoulder or pro- 
jection left at the neck of the tooth, but the cut sur- 
face should be plain from the crown to its termination 
at or near the neck. The space of whatever form it 
may be should be large enough to enable the operator 



FILLING BY CLASSES AND MODIFICATIONS. 207 

to manipulate with facility, and to see as directly as 
possible into the cavity. 

Cavities of this class are various in form; and they 
require much skill in their excavation and formation. 
Great care is to be exercised not to leave any portion 
of decay in them. By a fatal oversight, decayed den- 
tine is often permitted to remain on that side next to 
the neck of the tooth; and we have seen fillings that 
in other respects were good, very deficient here; so 
deficient, indeed, that a sharp instrument would 
readily penetrate the softened dentine above them, 
or even pass between the filling and the wall of the 
cavity. The removal of the decay from the cervical 
walls of all proximal cavities is an important particu- 
lar, neglect of which occasions thousands of failures. 
This class of cavities at this point should be most 
thoroughly filled; for it is a point more vulnerable 
than any other, on account of the facility with which 
foreign substances are here lodged and retained. 

In the formation of these cavities the cervical wall 
should be made to incline slightly inward, and the 
lateral walls, if the tooth will bear the loss, made at 
least parallel with each other;' but if that would im- 
pair its strength, grooves or pits may be made upon 
them for this purpose at proper points. When these 
cavities are large, the dentine is usually all decayed 
in that part of the cavity next to the masticating sur- 



208 CLASSIFICATION OF DECAYED CAVITIES. 

face of the tooth, leaving only the enamel, which by 
the mode of separating or opening, already described, 
would be cut away. 

Great care must be taken to arrange and dispose 
the napkins and bibulous paper so as to protect the 
cavity from moisture during the process of filling. A 
roll of paper should be placed on each side of the 
tooth, and on the paper the napkin, properly folded, 
should be laid, and kept in place by the operator with 
the left hand, or by the patient with the speculum. 
The gum between the teeth is liable to secrete mucus 
sufficient to moisten the work, or to be touched by 
the instrument so as to bleed; to obviate these diffi- 
culties, a wedge of wood, of the proper form, should 
be driven firmly in between the teeth below the 
cavity, so as to press the gum out of the way, and 
thus provide against both contingencies. In addition 
to these preparations, it will, in many cases, be ad- 
vantageous to place some appliance between the jaws, 
in order to keep them apart during the operation; in 
the absence of anything better a cork may be used. 
By this arrangement the mouth being propped open, 
the soft parts are sustained more in repose, and less 
saliva is eliminated from them to interfere with the 
work. 

With this preliminary the cavity is ready for the 
filling, which is introduced, if in blocks, as before de- 



FILLING BY CLASSES AND MODIFICATIONS. 209 

tailed, beginning with the cervical wall. The caution 
may here again be urged, not to let the gold overlap 
the tooth, particularly at the cervical wall. In filling 
with crystal gold or adhesive foil, special retaining 
points will be required in this wall, two being gene- 
rally sufficient, one toward the outer and the other 
toward the inner lateral wall, on both of which, 
grooves may be made, if the walls are thick enough 
to admit of it. If, however, these walls are not 
parallel, and will not admit of grooves, the crown and 
the cervical walls should be so shaped as to retain the 
filling. But in some cases the attachment of the fill- 
ing is made entirely at the cervical wall; and best by 
means of three pits, made with the square-pointed 
drill, at different angles, and in such directions as not 
to interfere with the pulp. This kind of attachment 
will serve only for adhesive gold, which is to be very 
thoroughly consolidated into the pits, making little 
projections, which are so many anchors for fastening 
the filling, and built very firmly across from one to 
the other. 

2d Mod. — Decay involving a portion of the masti- 
cating surface. . There are two methods of filling this 
modification. One is, to cut down the tooth or the 
projecting angles, and make a plain, oblique border 
to the cavity by the V-shaped separation already re- 
ferred to, and then fill up flush with this border. The 



210 CLASSIFICATION OF DECAYED CAVITIES. 

filling will thus exhibit a single, uniform surface, at a 
considerable angle with the axis of the tooth. When 
a portion of the crown breaks down in consequence 
of proximal decay, it is toward the center of the tooth; 
usually the inner and outer corners remain. If these 
projections are feeble and liable to be broken away, 
they should be cut down, and the cavity filled as 
before described. If, however, they are firm, they 
should remain, and the cavity,* properly formed, may 
be filled so as to restore the tooth's original form, 
which in the molars and bicuspids should be accom- 
plished as nearly as possible, in order that the func- 
tion of mastication should be perfectly preserved. By 
properly directed effort the crowns of the teeth can 
in almost all cases be well restored. Non-adhesive 
foil is not adaptable to this kind of filling, as it cannot 
be built in so as to withstand the pressure of masti- 
cation. In no case should a proximal filling be left 
in contact with the adjoining tooth. 

Fourth Class. — Proximal cavities of the incisors 
and cuspidati. If the teeth are not in a crowded 
condition, and the file is not required by the extent 
of the decay, separation may be made by pressure; 
but if the cavity is large, and the walls are thin and 
friable, cut with a thin chisel and file, only till a good 
border is obtained about the cavity. Much has been 
said as to the form of these separations, some recom- 



FILLING BY CLASSES AND MODIFICATIONS. . 211 

mending that they be larger at the palatine part 
than at the labial; others, that they be larger at the 
points than at the necks of the teeth; some, that a 
shoulder be left at the necks; and others, that there 
be no shoulder at all. In making these separations, 
however, the operator must be governed somewhat 
by circumstances, no general rule being applicable to 
all cases. The form of the teeth and the extent of 
the decay, together w T ith the character of the remain- 
ing enamel and dentine, will modify the form of the 
space, between them. If the inner wall is thin or 
broken away, — and it is usually more friable and 
more broken than the labial wall, — it should be cut 
off more than the outer; in which case the palatine 
portion of the separation will be the largest — as, in- 
deed, some prefer to make it in all cases, performing 
the remainder of the operation from the inside. Almost 
every operation upon these teeth will require attention 
and manipulation, in every step, from both the pala- 
tine and labial sides, in order to make secure every 
point. The precise mode of procedure nlust be de- 
termined by the case to which it is to be applied. 
The most direct approach is always to be employed 
when practicable. 

In some cases separation will be larger at the points 
of the teeth than elsewhere; as, where there has boon 
a partial fracture at the points. In cutting away to 



212 CLASSIFICATION OF DECAYED CAVITIES. 

make the separation, no shoulder should be left at the 
neck of the tooth that is not to be protected by filling; 
any projection of that kind is always objectionable: 
foreign substances lodge upon and adhere to it, and, 
becoming vitiated, render it very liable to decay. The 
cutting should always extend entirely beyond the 
decay, but only far enough to make a perfectly plain 
border to all the cavity, and should terminate without 
any projection. It is highly important, in separating 
the anterior teeth, to make as little alteration as pos- 
sible in their form. But the preservation of the tooth 
should not be jeopardized for the sake of maintaining 
the integrity of its natural form. The first consider- 
ation should be to obtain a space sufficient for the 
purposes of a perfect operation; the second, to have 
the walls and border of the cavity in such a condition 
that an efficient filling can be made; and the form and 
beauty of the tooth should be scrupulously preserved 
and protected so far as the above requirements will 
permit. 

The excavation of these cavities requires very deli- 
cate and skillful manipulation, since they are very 
readily injured by cutting too much or at a wrong 
point. All decayed and discolored portions must be 
entirely removed, as well for the appearance of the 
tooth as for the permanency of the operation; after 
which the cavity is to be formed with great care. At 



FILLING BY CLASSES AND MODIFICATIONS. 213 

the point of the tooth the dentine often has all been 
displaced by decay, leaving only the two plates of 
enamel joined at the edge, and thus forming an acute 
angle, the obliteration of which is always attended 
with risk, unless great care is exercised, and in many 
teeth it is wholly impracticable ; and still it is difficult 
perfectly to fill a very acute angle. The inclination 
of the inner and the outer walls of the cavity will 
depend on its size: when it is small or medium, 
they may be parallel, or, if necessary, slightly diverg- 
ent; but when large, it is better not to cut much of 
the healthy dentine from them, lest they be thus 
weakened. Small grooves, however, are admissible 
on these walls, near the bottom of the cavity, when 
they incline to the center, and are generally, in such 
case, to be preferred to pits. In the formation of 
grooves or pits for anchorages, the dentine should 
never be cut through to the enamel; but always den- 
tine sufficient to protect the enamel should remain. 
More cutting is allowable on the cervical wall than 
elsewhere, as there is less danger here of weakening 
the tooth by excavation. In filling with adhesive 
gold, we may, if necessary, rely exclusively on this 
part of the cavity for the retention of the plug; and 
the best method of preparing it is, to make two or 
three little pits in it at different angles with a fine, 
square-pointed drill. Another method is, to form two 



214 CLASSIFICATION OF DECAYED CAVITIES. 

pits, and make a groove from one to the other. Some 
operators prepare these cavities by making pits in 
each of the walls. This, however, is unnecessary, if 
the cervical wall is properly prepared. 

The cavity being prepared, the rolls of bibulous 
paper or napkin should be placed on the gum inside, 
and between the gum and the lip; and if the former 
has been wounded between the teeth, or if it elimi- 
nates mucus, a small piece of soft wood or of rubber 
should be crowded down upon it below the cavity. 
The gold, prepared as already described, should then 
be introduced with a small plugger serrated with four 
points, and somewhat flattened about a line above the 
point, so as to be freely used' when introduced into 
the cavity. The gold is taken up on the point of this 
plugger, and condensed in the pits of the cervical wall; 
which being completely rilled, and the gold extending 
from one to the other, the foundation is ready for the 
remainder of the rilling. 

Great care is requisite in packing the gold into these 
cavities, perfectly to adapt and adjust it to all points, 
so as to insure its thorough contact with every part 
of the interior. If the form of the tooth has been 
measurably retained, and the border of the cavity is 
even, the surface of the plug should, when finished, 
be slightly convex, or as nearly the original form of 
the tooth as practicable; and, in introducing the fill- 



FILLING BY CLASSES AND MODIFICATIONS. 215 

ing, reference should be had to this particular. Two- 
thirds of the cavity may be filled by introducing the 
gold upon and in the direction of the cervical wall, 
and the remaining portion filled from the point back 
to the preceding filling; or, what is probably better, 
begin at the bottom and fill to the surface, and then 
finish in the usual manner. 

For filling these cavities with non-adhesive foil, the 
special retaining points already described are not re- 
quired ; but the cervical wall of the cavity is slightly 
cut under, and the lateral walls so shaped as to secure 
the filling in place. These cavities are in some cases 
very difficult to fill with non-adhesive foil, whether in 
the form of blocks or otherwise, especially where they 
are large, with the walls inclined to the center, and 
the tooth bone friable. To force a .wedge-shaped in- 
strument into these fillings, for the purpose of con- 
densing them, is inadmissible, since there is thus great 
danger of breaking the walls of the cavity, and, in 
many cases, of moving the filling from its place. 

1st Mod. — The palatal wall broken away. Fractures 
of this kind assume different forms; sometimes trian- 
gular, extending from the border of the cavity toward 
the center of the tooth, and terminating in an acute 
angle; and sometimes the border of the cavity is 
broken away irregularly, or so as to form part of a 
circle. When a triangular notch is broken out of the 



216 CLASSIFICATION OF DECAYED CAVITIES. 

wall, the operation of filling may be performed in one 
of two ways: If the portions of the wall remaining at 
each side of the fracture are thick and firm, they may 
be left, and the cavity filled, so as to restore the form 
of both the proximal and the palatal surface of the 
tooth, the latter being thus restored with gold to the 
extent of the fracture or notch. If, however, the re- 
maining portions of the wall are frail, they should be 
cut away till a border is reached sufficiently firm to 
sustain the filling. Such cutting will leave the notch 
of a circular form, and, in many cases, will remove 
almost the whole of the inner wall of the cavity. As 
the decay extends toward the center of the tooth, 
owing to the concavity of its palatal surface, this wall 
becomes very thin and easily broken, this rendering 
it necessary to cut it almost all away; but, in all cases, 
the excavation should be such as to leave a definite 
wall, though it be but slight, all along that part of the 
cavity. In such a case, good retaining points must be 
made in the cervical wall, since the permanency of 
the filling will depend almost entirely upon these. 

The surface of the filling, when finished, may be 
slightly convex from one lateral wall to the other; the 
palatal portion of the surface, from the point of the 
tooth to its neck, will partake of the curvature of the 
border of the palatal wall; but the anterior portion 
will be only flush with the anterior wall. Much care 



FILLING BY CLASSES AND MODIFICATIONS. 217 

is requisite to give these fillings a perfect finish, on 
account of the irregularity of surface, this, in many 
instances, being both convex and concave. As a 
material for filling these cavities, adhesive gold is 
much to be preferred. Indeed, in many of them it 
is impossible, with non-adhesive gold, to make a per- 
fect filling, because they have no general embracing 
form. In such cases, the filling should be introduced 
from the palatal side of the tooth. 

2d Mod. — The labial wall of the cavity broken. 
The fractures of this wall are of various forms, and 
in extent corresponding with the amount of decay 
and the friability of the enamel. There is sometimes 
the triangular notch, extending far toward the middle 
of the tooth; and sometimes there are two or three 
small notches; and still in other cases, almost the 
whole of the wall will be broken away from the point 
to the neck of the tooth. When there is simply a 
notch in the enamel, it is important for the appear- 
ance of the tooth to fill it up; and when there is any 
prospect of success, the remaining portion of the wall 
being retained, the operation is to be performed as 
already described for the palatal wall. It will, how- 
ever, in many cases, be necessary to cut away part of 
the remaining portions of the wall, leaving the general 
form of the border somewhat circular; though the notch 
form, in some instances, is not wholly obliterated. 



218 CLASSIFICATION OF DECAYED CAVITIES. 

In filling this kind of cavity it is desirable to re- 
store as much as possible the form of the tooth. The 
filling should be built out from the border of the wall 
almost to a line with the tooth's original proportions, 
so that the whole surface of the rilling will be convex; 
and should be finished with great care, the Scotch- 
stone or stipple finish being preferable for that part 
exposed to view. 

3d Mod. — The cavity extending almost to the point 
of the tooth, and terminating, or cropping out at the 
surface. In the preparation of this cavity, that part 
next the point of the tooth should be cut in enough 
to form, a definite wall there, and to give room for 
sufficient thickness and strength in that portion of 
the plug. Many operators attempt to fill this kind 
of cavity without such precaution, terminating that 
part of the plug in a thin edge. This method is very 
objectionable; for the thin edge will become more or 
less separated from the tooth, and foreign substances 
will be forced under it, and, becoming vitiated, induce 
decay. Indeed, a defect of this kind is a sure pre- 
cursor of the destruction of the filling. The introduc- 
tion and finish of the filling in this kind of cavity are 
the same as first described for this class; and the ad- 
monition may be repeated, that there be left no thin 
overlappings of the filling that may become changed 
in position. 



FILLING BY CLASSES AND MODIFICATIONS. 219 

4th Mod. — The cavity large, and the lateral walls 
thin and friable. In this kind of cavity the dentine 
is almost entirely removed from the lateral walls, 
leaving little else than the enamel after the excava- 
tion of the decay. These walls will, of course, admit 
of no cutting for the purpose of giving them a more 
desirable form. The cervical wall must be shaped 
with special reference to a retention of the filling, to 
consolidate which the requisite pressure must be ap- 
plied almost exclusively toward this wall. It requires 
extreme care to condense the gold in cavities of this 
kind and adapt it to the lateral walls without fractur- 
ing them; and various methods have been suggested 
to prevent such an accident. Pluggers with very fine 
points are recommended, ^as consolidating the gold 
with much less pressure than would be necessary with 
large-pointed instruments. But it has been maintained 
that a perfect adaptation of the gold to the inner parts 
of these walls is not important, provided the adapta- 
tion at the border is perfect. It is certain, however, 
that a filling thus imperfectly adapted, is not so good 
as though the gold were in contact with all points of 
the cavity; and besides, the liability of fracturing the 
wall is just as great in consolidating at the border as 
within. The walls may be sustained by enveloping 
the tooth to the borders of the cavity with some ma- 
terial perfectly adaptable to it, and capable of resisting 



220 CLASSIFICATION OF DECAYED CAVITIES. 

the force applied in the process of consolidation, as 
gutta percha or plaster of Paris. If the former is 
employed, it should be softened by warming, moulded 
upon the tooth, and then permitted to harden. The 
hardening may be facilitated by throwing cold water 
on it from a syringe. It is then to be trimmed even 
with the border of the cavity, so as to admit the fill- 
ing. If plaster of Paris is used, it should be the best 
article. Yet gutta percha is to be preferred. But a 
better protection than either may be made of cheo- 
plastic metal, taking an impression of the tooth, and 
from that moulding the shield ; and this material is 
always to be recommended in extreme cases. In 
these fillings, when the enamel is clear and translucent, 
the gold will be visible through it. To obviate this 
difficulty, some appropriate substance may be placed 
between the outer wall and the gold — some substance 
that will restore the natural color of the tooth. Quill, 
horn, paper, and asbestos have each been employed 
for this purpose. Horn is, perhaps, the best material, 
as it can generally be selected of a suitable color. A 
thin lamina of this may be obtained by pounding a 
piece of the horn for a few moments, till a layer is 
detached; which may then be dressed down to the 
proper size, softened in warm water, and placed in 
the cavity next to the outer wall, yet so as not to 
extend quite to the border. The presence of this 



FILLING BY CLASSES AND MODIFICATIONS. 221 

substance makes the operation of filling a little more 
complicated; but the horn being softened, is easily 
pressed to the side of the cavity and conformed to it; 
and it may be made to retain its place, when first in- 
troduced, by touching it at one or two points with 
some adhesive material; or it may be made very soft, 
adjusted in the cavity, and then conformed completely 
to the wall by a temporary filling of gutta percha, 
which, after having chilled and stiffened, may be re- 
moved, leaving the horn thoroughly adapted and ready 
for the gold. 

Another method, which in many cases is preferable 
to either of the above is, after the cavity is formed 
and thoroughly cleansed, to fill it with os artificial, 
and after it has become hard, cut it out, leaving enough 
to constitute a good lining and support to the thin 
walls. The natural color of the tooth may be in this 
way so well restored and maintained as to elude de- 
tection; at the border of the orifice the gold should 
come in contact with the dentine or enamel. In 
almost all cases of thin weak borders, the gold should 
be built on and over them, so as to form a shield or 
protection against fracture or undue wear. All such 
overlapping portions should be made so thick and firm 
as not to be displaced or moved. 

The loss of a portion of the cutting edge of the in- 
cisors by extensive decay is often met with. In all 



222 CLASSIFICATION OF DECAYED CAVITIES. 

such cases, when the dentine is of good structure, it 
is practicable to restore the lost part to a greater or 
less extent by building up with gold. In order to 
make successful operations in such cases several points 
must be regarded; the dentine and enamel should be 
of good structure ; the cavity toward the neck of the 
tooth of such a form as to afford the best anchorage; 
this may consist of pits with grooves running out from 
them. Teeth with thick short crowns present the 
best opportunity for such an operation; indeed, upon 
that class of incisors with long thin crowns, such an 
operation is not usually practicable; and, generally, 
these teeth present such a contrast in color with the 
gold as to be quite objectionable. In the operation 
the manipulation must be such as to secure the 
most thorough welding of the portions of gold. of 
which the filling is composed. With good attach- 
ments, gold well prepared and in good condition, and 
properly manipulated, the golden portion of a tooth 
may be built up to any desired extent without danger 
of being either drawn out or broken down. The finish 
should be such as has already been described for fill- 
ings exposed to view. 

Fifth Class. — Posterior proximal cavities of the 
molars and bicuspids. These are separated like ante- 
rior proximal cavities, except that, ordinarily, to open 
them up, more is to be cut from the tooth, on account 



FILLING BY CLASSES AND MODIFICATIONS. 223 

of the greater difficulty of approaching, inspecting and 
operating in the cavity. The same general principles 
are applicable to the opening of this class of cavities, 
as to that of the third class, except that pressure can- 
not be as frequently employed, since the cavity will 
not be as well exposed by this as by cutting, nor ren- 
dered so easy of approach. Indeed, in operating on 
these cavities the use of the mirror is often necessary, 
it being impossible to obtain a direct view into them, 
after having cut away all that it is admissible to re- 
move. This difficulty is almost wholly obviated by 
the method of working through the masticating sur- 
face of the tooth into the cavity of decay, as already 
described. The accessibility of these cavities will 
depend on circumstances; such as the location of the 
tooth, its inclination, the size of the mouth, the flexi- 
bility of the muscles, and the ability of the patient to 
open the mouth and keep it open. Generally, in ope- 
rating on these cavities, for the removal of decay, for 
the formation, and the filling, curved instruments will 
be required ; but their curvature should not be greater 
than the necessity of the case demands. 

The cavity, during its preparation, must be fre- 
quently examined. Its general form, and the size, 
kind, and location of. the retaining-points will be the 
same as in class third. The lateral walls, if the cavity 
is not too large, should be made parallel with each 



224 CLASSIFICATION OF DECAYED CAVITIES. 

other; the undercutting at the crown wall will be less 
than in anterior proximal cavities; and the cervical 
wall should have the same general form as in other 
cases. In this latter there should be made, at differ- 
ent angles, pits for retaining-points — three, if the tooth 
is a molar, and two if a bicuspid. For making these 
pits, Merry's drill will be found more convenient than 
any other instrument. 

Preparatory to introducing the rilling, the same ap- 
pliances should be used to protect the cavity from 
moisture that have been indicated in modification first 
of class third. Crystal gold makes a better beginning 
for these fillings than foil; and hence the retaining- 
points should be filled up with it, and an attachment 
made from one to the other; on which foundation 
adhesive foil may be built, almost up to the crown 
wall of the cavity, and then the remaining portion 
filled from the bottom to the orifice, when the sepa- 
ration has been made by a V-shaped space, the filling 
should have a single plain surface, which will be at a 
greater or less angle with the axis of the tooth, accord- 
ing to the greater or less portion cut away in the 
separation. It is impracticable to build these fillings 
up as some of those in the anterior proximal cavities 
may be, because of the difficulty of thoroughly con- 
solidating and finishing their proximal portions, 
especially near the neck of the tooth; though the 



FILLING BY CLASSES AND MODIFICATIONS. 225 

difficulty is somewhat obviated by placing a piece of 
polished metal, of the proper thickness, back of the 
cavity, against the adjoining tooth, introducing the 
filling, and consolidating it firmly up to this piece of 
metal : the lost portion of the crown being thus 
restored, the metal is then removed, and the filling 
dressed off and finished in the manner described 
heretofore. But when the opening is made by cut- 
ting in. from the masticating surface, the entire 
opening, made in the tooth, both by the decay and 
the operation will be completely filled, and the form 
of the tooth entirely restored ; the filling will then 
present a proximal and crown surface. When the 
teeth, molars and bicuspids, are decayed upon their 
contiguous sides, the cavities in both may be prepared 
as already described, the proper separation and 
excavation having been made, both are filled together, 
the gold extending across the space, and after being 
filled up flush with the masticating surfaces, the 
separation is effected by dividing the gold with a 
separating file : thus, each cavity is completely filled 
and there is always gold enough upon the proximal 
parts to secure a complete finish. This method is 
not always practical, as for instance, when there is a 
large space, or when it is not desirable to fully restore 
the form of each tooth, but in some cases it may be 
used with decided advantage. The labor, tedium. 



226 CLASSIFICATION OF DECAYED CAVITIES. 

and difficulty of manipulation are increased the farther 
back in the mouth the decay is situated. The modi- 
fications of this class are the same as those of the 
third class of cavities, and, except the second modifi- 
cation are susceptible of the same methods of filling. 
Special Cases. — The first case that we shall con- 
sider here, consists in a complication of proximal 
decay with decay on the buccal or palatal portion of 
the tooth, thus undercutting one of the crown angles. 
Sometimes these decays are on both sides, in the 
form of transverse grooves, meeting at the corner of 
the tooth. In such cases, if the pendent crown 
angle of the tooth is firm and strong, the cavities 
may be formed in the proper manner, and filled 
without interfering with the masticating portion of 
the tooth at all ; but, if the pendent portion is friable, 
it should be cut away, and the corner built up with 
gold. The method of forming the part to be filled 
will depend on the extent of the decay. When this 
is large, a greater number of retaining-points will be 
required than when it is small ; and these should be 
located at such parts as will make them most tena- 
cious of the gold, and least subversive of the strength 
of the tooth. The filling may be built up so as to 
restore the original form of the tooth, thus presenting 
three surfaces, the proximal, the buccal or palatal, 
and the masticatory ; or, it may be made with a single 



FILLING BY CLASSES AND MODIFICATIONS. 227 

slightly convex surface, adapted and finished most 
completely at all its borders. This kind of filling 
can be made only with adhesive gold. 

The palatal portion of the crown broken away, leav- 
ing the outer portion standing — nerve not exposed. — The 
tooth, in such case, is decayed away so that the floor 
of solid dentine is near the margin of the gum, the 
labial third of the crown still standing. The decay 
having been all removed, four or five little pits 
should be made on this floor, as near its circumfer- 
ence as practical ; and a small groove may be cut 
from one of these pits to another all round near the 
edge of the floor. Then two little pits should be 
made at the base of the standing portion of the 
crown, if practicable, without interfering with the 
pulp, provided it is still living. The decayed part 
thus prepared, a sufficient shield, in the form of 
paper, folds of napkin, or the rubber-dam which is 
preferable, is to be thrown round the tooth, to protect 
it against moisture during a protracted operation : in 
this particular great care is necessary. 

For building up a crown of this kind, only adhesive 
gold can be used ; and this should be of the best prep- 
aration, and in the most perfect condition, since it 
is important that the different portions of the filling 
be most thoroughly united. The instruments em- 
ployed in the operation should be of the best kind 



228 CLASSIFICATION OF DECAYED CAVITIES. 

and in the best condition, the serrate points being 
definite and sharp, though not too long : those with 
four, six, or eight points may be advantageously used 
for packing the gold. But care must be exercised 
lest these fine points be turned ; for when that is the 
case, the instrument is liable to displace the portion 
of gold, and thus break up its first attachment during 
the process of consolidation ; and when this is broken, 
the piece of gold can not again be made to adhere as 
perfectly as before. 

With every thing thus in readiness, the retaining- 
points are all to be filled, the gold extending from 
one to the other ; which is then to be built all over 
the bottom of the part to be restored, projecting a 
little beyond the periphery, and being perfectly con- 
solidated there, and kept somewhat higher round the 
border than in the center. The gold should be built 
on in this manner till the crown is large enough, 
after dressing, to give the desired size and form. In 
finishing up, the aim should be, to restore as perfectly 
as possible the lost form of the tooth. The adaptation 
of the gold, too, to the standing portion of the crown 
should be most complete ; imperfection in this respect 
impairs the appearance of the work, and jeopardizes 
the security of the operation. 

Occasionally the crown of a molar tooth is found 
decayed off all round, almost to the margin of the 



FILLING BY CLASSES AND MODIFICATIONS. 229 

gum, the pulp having previously receded so as not 
to be exposed. It is, in such case, desirable to re- 
store the lost portion of the crown, and make a mas- 
ticatory surface such as shall antagonize properly 
with the teeth of the opposite jaw. As yet, there is 
no other method of accomplishing this, than by build- 
ing it up with gold — adhesive gold foil or crystal 
gold. In the preparation for this crown of gold, the 
edge should be dressed smooth and even all round 
the tooth ; then six or eight deep pits should be made 
at different angles about on the base thus prepared ; 
and they should be bored with a drill larger than is 
commonly used for retaining-points. These pits may 
be slightly enlarged within. The method of building 
up the crown is just the same as that described for 
building up part of a crown, the pits being first filled, 
then joined together, and the gold extended all over 
the part to be covered by the filling. In extending 
the gold from a retaining point or points, it is neces- 
sary to build up to a considerable thickness above the 
orifice of the pit. The portion of gold extending 
along on the tooth from the pit, should be quite thick 
and firm, so as not to curl up from its position, on 
the addition of subsequent portions. Every particle 
of gold, indeed, should be so manipulated, that it will 
securely maintain its first position. The permanency 
of the operation will depend very much upon this 



230 CLASSIFICATION OF DECAYED CAVITIES. 

precaution. The gold should extend somewhat be- 
yond the circumference of the tooth all around, in 
order to a thorough adaptation and finish. 

The foundation thus prepared, and kept free from 
moisture, the crown is easily built up by the ordinary 
method of packing the gold. Any desired shape can 
be given to this artificial crown ; but, of course, that 
which most nearly resembles the form of the natural 
crown, is in all cases to be desired. The masti- 
cating surface of this gold crown is to be formed from 
the indications given by the antagonizing teeth. 
Such crowns will wear for years, and perform all the 
functions of the natural organs. Artificial crowns of 
this kind have been attached to the tooth, by screw- 
ing into the pits small pieces of gold wire at different 
angles, and then building up round and between 
them with the gold foil, on the principle already 
described, thus making these wires serve as so many 
anchors for fastening the work. This, however, is a 
less efficient method than the one first described, 
since there is no cohesive attachment of the foil to 
these gold anchors, and it is retained in place only 
by the mechanical arrangement of the wires ; but by 
barbing or roughening them, or giving them abrupt 
curves, they may be made to retain the crown well, 
if it is thoroughly consolidated and united. But the 
method of anchoring with foil, as before observed, is 



FILLING BY CLASSES AND MODIFICATIONS. 231 

always to be preferred, since by this there is a weld- 
ing of the entire mass, and an anchorage, too, quite 
sufficient in all cases to retain it in its place. 

Filling large cavities on the labial surfaces of the 
superior incisors. — These cavities are usually super- 
ficial, and frequently co-extensive with a considerable 
part of the surface of the tooth. A method of filling 
them, somewhat novel, though not without merit, has 
been introduced to the notice of the profession by 
Dr. Volck, it having been first suggested to him how- 
ever, by Dr. Maynard. It consists in filling up the 
cavity principally with a piece of enamel, as near the 
color of the tooth as possible. The cavity, when 
nearly round, should be formed with a wheel bur of 
the proper size ; and after having been thus reamed 
out, a slight under-cutting should be made all round 
with an excavator. Then a piece of enamel being se- 
lected, it is dressed to a proper thickness, which should 
be slightly greater than the cavity's depth, and' to a 
perfectly circular form, its size being such as to let it 
drop, with a little play, into the cavity, and the edge 
of it being beveled from without. For fastening this 
in the cavity, roll a strip of several thicknesses of 
gold foil round its edge, and add as much as can be 
forced in with it ; set it all in place in the cavity, 
and then condense the gold down into the groove all 
round with a thin-pointed plugger, more gold being 



232 CLASSIFICATION OF DECAYED CAVITIES. 

added, if necessary, to fill the groove completely full. 
Afterwards, with the file, stone, and burnisher, dress 
off the whole to a proper level with the surrounding 
tooth, finishing very carefully with the burnisher. 
The unsightliness of a large gold filling on a front 
tooth is thus obviated, no metal except that compo- 
sing the ring of attachment in the groove being ex- 
posed to view. It is a beautiful operation, and one 
whose successful accomplishment will require con- 
siderable constructive talent and skill. 



CHAPTER VIII. 

PATHOLOGICAL CONDITIONS. 

Hitherto, in our consideration of the treatment of 
caries, we have postponed the subject of the vitality 
and pathology of the teeth altogether. It now re- 
mains to describe the diseased conditions to which 
the teeth are subject, and the treatment which those 
respective conditions indicate. This is an important 
department of the practice, since upon skill in this, 
as well as upon the manner of performing the work, 
the success of the operation depends. 

Premising that our remarks on this branch of the 
subject are predicated on the fact admitted, that the 
teeth possess vitality, we proceed to consider the 
pathological conditions to which, in common with all 
vital tissues, they are liable. There is but one diseased 
condition of living dentine, anterior to decay, that pre- 
sents any considerable difficulty in the ordinary opera- 
tion of filling teeth, and that is, inflammation, or exalted 
sensibility. This condition was referred to in the 
remarks on the treatment of caries, as being one that 
most generally accompanies decay of the teeth. 
Whether or not this affection is real inflammation, is 



234 PATHOLOGICAL CONDITIONS. 

a point that has been considerably controverted ; and 
the assertion has been made, that it is of no conse- 
quence whether it is or not, provided we understand 
the true method of treating it. This, however, is 
not to be so readily conceded ; for the confession that 
we do not know what to call a thing, generally im- 
plies an ignorance of its character and phenomena; 
while the term inflammation conveys a more definite 
notion, the phrase exalted sensibility is very vague 
in meaning. That it is true inflammation, is the 
opinion of our best dental writers. 

The dentine is endowed with the functions of 
absorption, nutrition, and secretion — characteristics 
that always imply a susceptibility of inflammation. 
In inflammation of the soft parts, there are present 
various indications ; as, pain, redness, swelling, and 
increased heat. But in dentine, on account of its 
peculiar structure, all these indications can not be 
manifested : for instance, redness, since the red 
globules do no circulate through it; nor swelling, 
since the structure is too dense; nor perceptibly 
increased heat, since the circulation is of too low a 
grade. But, one of the most definite indications of 
inflammation, namely, exalted sensibility, is present 
here in all its force. And there are various other 
circumstances that indicate this condition to be real 
inflammation : the same irritating causes that induce 



PATHOLOGICAL CONDITIONS. 235 

inflammation in the more highly organized parts, 
occasion it in the living dentine ; this condition of 
the teeth is always affected by a general inflammatory 
diathesis, and their sensitiveness, when there is this 
general tendency to inflammation, is always increased, 
and local treatment in such case will commonly be 
inefficient ; a modification of such a condition of the 
system produces a very corresponding change in the 
affected teeth ; and those remedial agents which are 
employed in the topical treatment of inflammation 
elsewhere, are successfully used in the treatment of 
inflamed dentine. From all these circumstances we 
infer that this affection of the teeth is a real inflam- 
mation. 

As it has been already remarked, the only definite 
and direct indication of inflammation of the dentine, 
is exalted sensibility ; though this is not an immedi- 
ate consequence of that condition, independent of 
external circumstances; for the pain resulting directly 
from inflammation in the soft parts, is not experi- 
enced here, by reason of the low grade of vitality and 
the feeble circulation. But the teeth, in a state of 
inflammation, will suffer pain when subjected to sud- 
den variations of temperature, whether induced by 
the air, by fluids, or by any hard substance; and 
w 7 hen subjected to the influence of agents that irri- 
tate the nerve-tissue anywhere, such as acids, some 



236 PATHOLOGICAL CONDITIONS. 

alkalies, salts, &c. In regard to degree, extent, 
and location, this affection exhibits a variety of 
manifestations; in degree, from the most mild to 
the most intense — sometimes fixed at a uniform pitch 
of pain, and sometimes passing through the gamut of 
torture up to the most acute anguish. The character 
of the affection is modified by differences in the 
organic structure of the teeth, those most vascular 
and most highly organized being most readily and 
most extensively involved ; and therefore the teeth 
of the young are generally more liable to it than 
those of the old. So, too, persons of a plethoric or a 
strumous habit, as well as those in a febrile condi- 
tion, are peculiarly predisposed to this affection. 
Sometimes irritation or disturbance of other organs of 
the system, sympathetically or secondarily induce 
inflammation of the dentine. Uterine irritation fre- 
quently does so ; and hence, during pregnancy or a 
protracted suppression of the catamenia, the teeth are 
very liable to be thus affected, and, if decayed, to 
become very sensitive. 

Inflammation of the dentine will sometimes be 
exhibited in various degrees in different teeth in the 
same mouth at one time. This is owing to differ- 
ences in the organic structure of teeth developed at 
different periods of life, to differences of their loca- 
tion in the mouth, and to differences of exposure to 



PATHOLOGICAL CONDITIONS, 237 

those agencies which are apt to induce the condition. 
As to the extent of this inflammation, it may be con- 
fined to a thin lamina of bone immediately beneath 
the decomposed portion, or may extend deep into the 
body of the tooth, and, indeed, in some cases, pervade 
the dentine of the entire crown. This latter extent, 
however, it is not likely to have, unless there is a 
general predisposition : if it is produced by local 
causes, it will not, in general, penetrate very deeply 
into the dentine. Most commonly, the greatest 
sensitiveness is at the union of the dentine with 
the enamel; but, sometimes, it is confined to a small 
point within the cavity, either because there is a 
concentration of nerve-fibrils there, or because there 
has been a determination of the irritating influences 
to that point — the former being probably the more 
frequent. The greatest sensitiveness, as already re- 
marked, is generally at the surface of the dentine, 
because that is the termination of the nerve-fibrils 
which ramify the dentine, and wherever nerve-fiber 
terminates, there always we may look for exalted 
sensibility. Hence it is, that decay of the teeth is 
often found to be more sensitive in its incipient 
stages, than when it has become more advanced. 

Treatment of Inflamed Dentine. — There are several 
methods of treatment that may be employed to 
remedy this condition. In many cases, whore time 



238 PATHOLOGICAL CONDITIONS. 

and circumstances will permit, a removal of all irri- 
tating agents from the affected parts, will enable 
nature alone to affect a restoration to health. All 
decomposed dentine is to be removed from the cavity, 
every exciting influence in it withdrawn or neutral- 
ized, and the cavity itself perfectly rilled with some 
non-conducting material, so as entirely to exclude all 
foreign substances. This material may be Hill's 
Stopping, or os artificial ; — and this, in the property 
of non-conduction, is superior to any other ; — or, in 
some cases, it may be tin or gold ; but, when either 
of these is employed for the purpose of such tempo- 
rary filling, some non-conducting substance should be 
placed between it and the sensitive dentine. The 
length of time necessary for a restoration of the 
affected part, under this treatment, will be much 
varied by circumstances. The cases susceptible of 
this kind of treatment are those in which there is no 
constitutional predisposition, in which the vitality is 
strong, and the recuperative power vigorous. When 
the temporary fillings are made of metals, the patient 
should be careful to protect them from sudden changes 
of temperature. For such fillings, in case they are 
required but for a short time, a lock of cotton satu- 
rated with a solution of gutta percha and chloroform, 
may be used. 

But, in cases in which the vitality is low, the 



PATHOLOGICAL CONDITIONS. 239 

affection chronic, the exciting cause highly irritating, 
and the general diathesis inflammatory, nature, un- 
aided will not affect a cure. In such circumstances, 
therapeutic treatment is indicated. The agents em- 
ployed in topical treatment may be divided into two 
classes : first, resolvents, or those which have for 
their object an entire restoration to health of the 
part affected; and second, escharotics, or those which 
have for their object the death of a portion or all of 
the diseased part. The former class of agents is of 
course preferable, when the object can be promptly 
accomplished by their use, and especially preferable 
to those agents which endanger the vitality of the 
whole tooth. In very many cases in which topical 
applications are indicated, constitutional treatment is 
also required ; and this should be of an antiphlogistic 
character. The immediately adjacent parts, too, as 
the gums, the mucous membrane, etc., should be 
carefully regarded. Indeed, treatment of the gums 
by counter-irritation, depletion, and various prepara- 
tions, such as the conditions may indicate, will often 
be found pre-requisite to a successful treatment of 
sensitive dentine by topical applications. 

There are very few agents used simply as resolv- 
ents. The properties characteristic of this class of 
agents are tonic, stimulant, sedative, and astringent. 
Tincture of capsicum may fitly represent the stimu- 



240 PATHOLOGICAL CONDITIONS. 

lant; Peruvian bark, and gum myrrh, the tonic; 
tannin the astringent ; and opiates the sedative prin- 
ciple. Astringents, stimulants, and sedatives all tend 
to counteract inflammation. The agents of this 
class are not very extensively used in the treatment 
of dentine, not because they are not ultimately effi- 
cient, but because their action is less vigorous than 
that of some other agents. When, however, time 
and circumstances will permit, mild treatment, if 
efficient, is to be preferred. 

But there are many cases in which, for want of 
time, something more rapid in its action is required. 
Of this character is the second class of therapeutic 
agents, namely, escharotics, or those which, by their 
action, destroy a portion of the tissue with which 
they come in contact. It may be well to notice, 
separately, the preparations commonly used for this 
purpose. 

Tannin, or Tannic Acid. — This is the active prin- 
ciple of vegetable astringents, and is found most 
abundant in nutgalls. It unites with albumen, fibrin, 
and gelatin, forming with them insoluble tannates. 
Its medicinal influence is almost necessarily topical, 
since the promptness of its action on albuminous sub- 
stances, and the insolubility of its compounds with 
them, prevent its admission into the general circula- 
tion. The action of tannin on dentine has been 



PATHOLOGICAL CONDITIONS. 241 

already explained. Either its aqueous or its alcoholic 
solution may be employed; the latter being the better 
and more convenient preparation. It is however 
recently used by solution in creosote and glycerin, 
which constitute very valuable preparations. Where 
tannin is applied to dentine, there is formed a tannate 
of albumen, which, being insoluble, protects from irri- 
tation, and probably incites to healthy condition, the 
living parts beneath it. 

Creosote, or Carbolic Acid. — Formerly, creosote was 
obtained by distillation of wood, and differed some- 
what from that in present use, which is prepared by 
distillation of coal tar. It dissolves freely in alcohol or 
ether, and sparingly in water • its action may therefore 
be modified by dilution. Creosote produces its caustic 
effects by its affinity for albumen and gelatin, with 
which it forms insoluble compounds ; and from its 
modus operandi, it is evident that the popular opinion 
that it promotes decay of the teeth is an error. 

Nitrate of Silver. — This salt is a powerful caustic, 
whether applied to soft parts or to bony tissue. Its 
action is somewhat complex. Nitric acid is liberated 
by the decomposition of the salt, when in contact with 
organic matter. Nitrate of silver has a strong affinity 
for albumen, uniting with it without difficulty ; and 
the compound thus formed, is soluble in nitric acid. 
When the nitrate is applied to the skin, the immediate 



242 PATHOLOGICAL , CONDITIONS. 

result is a whitish mark, caused hj a union of the salt 
with the albumen of the cuticle ; but this soon turns 
black, by the reduction of the salt and the liberation of 
the oxide of silver ; when, for each atom of this set 
free, there is liberated an equivalent of nitric acid. 
There is here, then, an agent that acts promptly on the 
gelatinous portion of the tooth, destroying its vitality 
to the extent of the combination which takes place, and 
that, by the decomposition of part of the salt, and the 
consequent liberation of part of the acid, also acts 
with energy on the calcareous portion. The compound 
formed by the nitrate with the organic constituents 
of the tooth, is insoluble except with a few substances, 
and therefore protects the subjacent parts ; and the 
precipitation of the reduced oxide on the surface, it is 
claimed, affords some additional protection. The in- 
solubility of the compound above mentioned, prevents 
an absorption of the nitrate by the dentine, and ren- 
ders its action necessarily superficial. When the 
nitrate is neutralized by a union with it of an equiva- 
lent of the constituents of the dentine, no further 
chemical action is possible. The compound formed by 
this union is soluble in a dilution of the nitrate ; and 
if this be applied in too great a quantity, there may 
be a larger loss of substance than is desirable or at all 
necessary; for, as long as free nitrate remains in 
solution in the- cavity, the insoluble compound is not 



PATHOLOGICAL CONDITIONS. 243 

precipitated, and the surface is therefore exposed to 
the continued action. It is preferable to employ the 
nitrate in the solid state, or, when this is not practi- 
cable, in a concentrated solution and small quantity, 
rather than in a copious dilution and repeated appli- 
cation. 

From the observations already made, it is quite 
evident that no harm can result to the tooth from a 
proper application of this agent, beyond the portion 
of it immediately acted upon. The nitrate can not 
be absorbed by dentine, but it stimulates the sub- 
jacent dentine to more healthy action ; though some 
maintain that it is not as efficient in this respect as 
some proper chlorid. It acts to a greater depth than 
tannin or creosote, but not so deep as chlorid of zinc, 
nor with so much pain. Great care should be exer- 
cised that its contact be permitted no further than its 
action is desired. 

Chlorid of Zinc, — This agent has been extensively, 
though much less now than formerly, used in the 
treatment of sensitive dentine. It exerts an anti- 
septic and disinfectant, as well as an escharotic 
influence. In its operation it decomposes, the chlorine 
uniting with the animal and the calcareous elements 
of the dentine. It is milder in solution than in solid, 
and less efficient and less painful. It is soluble in 
water, alcohol, ether, or chloroform. The etherial 



244 PATHOLOGICAL CONDITIONS. 

and the chloroform al solutions are, in their action, 
least painful of all the forms in which this chlorid is 
applied. The union of this agent with the gelatinous 
constituent of the tooth is also more prompt in solution 
than in solid. The ether and the chloroform may 
lessen the pain by their anaesthetic influence. In the 
use of the chlorid or any other active caustic, it is 
important to hear in mind the exalted vitality which 
follows its application ; and the operation should be 
immediately performed. In the teeth of young 
persons, or those in which the animal constituent 
greatly predominates, the vitality will be more 
promptly aroused than in those of an opposite texture, 
and the change, too, will be greater. If the inflamma- 
tion is confined to a thin lamina, it will be almost 
instantly allayed by the application of the chlorid, 
and the cavity may be excavated, as though there 
had never been exalted sensibility ; but if the opera- 
tion be delayed any considerable time, the tooth will 
often be found in a worse condition for excavating 
than before the application. The remarks on absorp- 
tion under the head of nitrate of silver, apply with 
equal force here : there is not the least danger from 
this source ; indeed, there can be none ; even when 
the chlorid is applied to the soft parts. 

Ter chlorid of Gold. — Of this preparation the ethe- 
rial solution only has been employed. This acts with 



PATHOLOGICAL CONDITIONS. 245 

great promptness on the dentine, forming an insoluble 
compound with the gelatinous elements, and the 
chlorine of it forming also a combination with the cal- 
careous portion. On account of the promptness with 
which this agent operates, neither the pain nor the 
disturbance of the subjacent parts caused by it, is 
great. This substance is very liable to decomposition. 
By exposure, to air or light, the gold is precipitated 
in the metallic form. But, protected from these, it 
may be preserved for a long time. This agent will 
not be absorbed by the dentine. 

Arsenious Acid. — The modus operandi of this agent 
is involved in obscurity. In regard to its topical 
action, Professor Bache, says : "Arsenious acid, when 
it produces the death of a part, does not act, strictly 
speaking, as an escharotic ; it destroys the vitality of 
the organized structure, and its decomposition is the 
consequence. The true escharotic acts chemically, 
producing a decomposition of the part to which it is 
applied; a state incompatible with life." Pereira 
says : " Though employed as a caustic, yet the nature 
of its chemical influence on the animal tissue, is un- 
known; hence it is termed by some a dynamic caustic." 
Its escharotic power certainly bears no proportion to 
its devitalizing power; but it is probable that it forms 
definite compounds with some of the constituents of 
living tissue; and if so, these compounds appear to be 



246 PATHOLOGICAL CONDITIONS. 

readily and rapidly decomposed, so that the acid be- 
comes again free to attack, with similar results, the 
subjacent parts. The topical application of arsenic is 
liable to be followed by constitutional effects. 

All dentists are aware of the fact that a tooth-pulp 
may be destroyed by arsenic, through a wall of con- 
siderable thickness. To accomplish this, the agent 
must in some way penetrate the substance of the 
dentine; and its vitality is destroyed so far as it is 
thus penetrated; indeed, the vitality of the whole 
crown of the tooth, both dentine and pulp, is often 
destroyed by the use of this remedy, applied even to 
a small cavity. Exalted sensibility of dentine is 
subdued by this agent, more by its devitalizing than 
through its chemical energy. It is soluble in creosote 
and similar oils, and, to a considerable extent, in 
alcohol and water. It is absorbed much more rap- 
idly when applied in solution than in solid ; and the 
more vascular the dentine, the more rapid and exten- 
sive will be the absorption ; and on this account there 
is great risk in applying it to the teeth of young per- 
sons, or to any teeth that are highly wanting in den- 
sity ; indeed, it will destroy the vitality of very dense 
teeth. The manner in which it passes into the den- 
tine, is not very definitely understood. It is very 
certain, however, that in more highly organized 
parts, it is carried through by the circulation, and 



PATHOLOGICAL CONDITIONS. 247 

also may be taken up by imbibition. In either of 
these ways it may pass into the dentine, and so far as 
concerns the results, it matters not in which way. It 
is enough to know that there are well defined cases 
of its specific effect on the constitution, after having 
been applied to toothbone — demonstrating that it 
must have been taken up by the circulation; and 
also cases of its manifest effect on the periosteum in 
a short time after having been applied to the cavity 
of a tooth, the pulp of which is dead — thus proving 
that it must have been absorbed by imbibition. 

If arsenic is ever employed in the treatment of 
sensitive dentine, it should be suffered to remain in 
the cavity but a short time — from one to three hours 
— and then the part with which it was in contact, 
should be very thoroughly excavated : and in de- 
ciding in what cases it is proper to use it, there is 
need of careful discrimination as to the tooth's struct- 
ure and density; for injurious results have some- 
times followed its application, notwithstanding the 
utmost care; if it has once been absorbed by the 
dentine antidotes will avail nothing. On the whole, 
therefore, it is better to refrain from its use altogether 
in the treatment of sensitive dentine. 

Alkaline caustics have been, to some extent, used 
for the treatment of this affection. A preparation 
made after the following formula, is said to relieve 



248 PATHOLOGICAL CONDITIONS. 

some cases very promptly : take Canada balsam and 
slacked lime, and, having made them into a paste, fill 
the cavity partially full with it, and permit it to re- 
main until the object is accomplished. 

The sensitiveness of dentine may be obtunded by 
thorough friction on the affected part with a smooth 
burnisher. This method, however, is applicable only 
to those cases in which there is room to use the in- 
strument. On the surfaces of the teeth, where there 
may be sensitiveness, it is very applicable and very 
efficient. Simple pressure, without friction, it is sug- 
gested, will accomplish the same object ; though 
pressure and friction combined, are doubtless more 
efficient. 



CHAPTER IX. 

EXPOSED PULPS. 

Usually, when the pulps of the teeth are exposed, 
it is in consequence of decay, but sometimes of a 
gradual wearing-down of the organs in mastication. 
When the pulp of a tooth is found exposed, the 
'course of remedy to be pursued, will be indicated by 
the following considerations: — 

1st. The constitution and the vital energy of the 
system. 

2d. The condition of the mouth and teeth. 

3d. The condition of the pulp. 

4th. The size of the orifice at which it is exposed. 

5th. Whether the exposure is of recent, or of 
remote origin. 

6th. If in a tooth of more than one fang. 

7th. The position of the tooth in the mouth, and 
that of the decayed cavity in the tooth. 

The propriety of attempting to preserve the vitality 
of the pulp after exposure, has been questioned. 
Some take the position that after the development 
and formation of the tooth, the pulp is no longer of 
any use, and may, without damage, be dispensed 



250 EXPOSED PULPS. 

with; while others maintain that, when the pulp is 
destroyed, the tooth is no longer of any value. The 
truth is, perhaps, a medium between these extremes. 
The pulp of the tooth is valuable in the economy, or 
nature would dispense with it. Analogy teaches 
that it would not be retained longer than it could 
subserve some beneficial purpose. But it is also 
true, that a tooth may be retained and perform its 
proper function for a long time after the destruction 
of its pulp, notwithstanding it is in a less perfect 
condition; though it is always desirable to preserve* 
the life of the tooth when practicable; for the crown 
depends on the pulp for its vitality, and living dentine 
presents more resistance to decay than dead; besides, 
a dead tooth never exhibits the bright, life-like 
appearance of a living one. The parts about a dead 
tooth, too, are far more liable to disease than those 
about a living one. These are only a few of the 
considerations for retaining the nerves of the teeth. 

It has been maintained that the structure of the 
tooth-pulp is of such peculiar character, and so sus- 
ceptible of diseased action, that after it has become 
affected, though but slightly, it can not be restored 
to a healthy condition. We see no ground, however, 
for such an assumption, except it be in the imperfect 
treatment which this organ so frequently receives; 
for the fact of its delicate structure does not neces- 



EXPOSED PULPS. 251 

sarily imply an impossibility of restoring it from 
disease. The pulp of the tooth is endowed with 
such functions as ordinarily render living tissue sus- 
ceptible of treatment for abnormal conditions; as 
circulation, nutrition, absorption, and a distribution 
of nerves. The success attending the methods of 
treating exposed pulps, practiced by the dental pro- 
fession during the last few years, is a source of more 
encouragement than a thousand theories. 

Treatment of Exposed Palps. — In cases where the 
conditions are favorable, — the constitution good, the 
pulp but recently exposed at a small orifice, and in a 
healthy condition, treatment may be instituted with 
considerable certainty of success. If there is no 
inflammation or irritation, therapeutic treatment is 
not indicated ; but the decay should be removed and 
the cavity formed without wounding the pulp, if 
possible ; though a slight wound is of no serious 
consequence; for immediately after the hemorrhage 
ceases, the operation may proceed as though the pulp 
were intact. There have been suggested various 
methods for protecting the pulp in cases of this kind : 
formerly, the capping of pulps was very extensively 
practiced; by which a shield was thrown over the 
exposed point, so as to prevent the filling from coming 
in contact with it. Various materials have been 
suggested and used for caps ; but gold and load have 



252 EXPOSED PULPS. 

been chiefly used for the purpose, especially when 
the object was to form an arch over the point of 
exposure. These caps are cut out of thin gold plate, 
or thick sheet lead, of the proper shape and size, and 
stamped with a convex punch, thus receiving such a 
concavity as fits them for covering the exposed pulp 
without touching it. A little groove, of depth suffi- 
cient to hold the cap and prevent it from being 
displaced by the introduction of the filling, may be 
made in the dentine all round the orifice of exposure. 
The cap is then to be adjusted to its position in the 
cavity, having been previously touched round its 
edge with adhesive wax, the filling is then introduced 
in the usual manner, carefully, so as not to displace 
the cap; and if this is of lead, great caution is to be 
observed in condensing the filling above it, since it 
will be easily compressed. 

The therapeutic influence of lead on exposed pulps 
is supposed by some to be definite and decided ; but, 
though lead is a less perfect conductor of heat, and 
in this respect is better than gold, and though, in the 
capacity of a pulp-cap, its indestructibility is probably 
quite sufficient, yet, if no change takes place in it, it 
is not very apparent how it exercises any therapeutic 
action on the pulp. Experience, however, proves that 
the success is quite as good in the use of lead caps as 
in those of gold; and the former are more easily applied. 



EXPOSED PULPS. 253 

Another method of shielding an exposed pulp is, to 
form an arch over it by the filling. This operation is 
performed by beginning the filling at that side of the 
cavity most easily approached, building on the gold 
from the points of its attachment almost to the point 
at which the pulp is exposed, and then attaching 
from one point to another without permitting the gold 
to come in contact with the pulp. Care should be 
taken that the gold present as smooth a surface to 
the pulp as possible. When the orifice of exposure 
has been well covered and protected, the remaining 
portion of the cavity is filled as usual. This method 
of forming a protection over a tooth-pulp, possesses 
no advantage over the ordinary cap ; and being much 
more difficult, it is impracticable in any but skillful 
hands. 

This practice with exposed pulps, however, has, 
within the last few years, been almost wholly aban- 
doned, and for the following reasons : because it so 
frequently failed to accomplish the object, and because 
a better method of treatment has been discovered. 
It was found that, muier that practice, many cases 
which at first promised well, failed to preserve the 
life of the pulp; though the fatal results were not 
always immediate, a year or two, and, in some in- 
stances, a much longer period, intervening between 
the operation and the death of the tooth. In favor- 



254 EXPOSED PULPS. 

able cases, the pulp, even after exposure, will, if 
protected from the influence of foreign substances, 
throw out a bony deposit, and even close up an orifice 
of exposure, thus forming for itself a natural shield. 
It is submitted that the capping operation is not the 
best protection for facilitating this jn'ocess. It is 
probable that, in some cases, the space between the 
cap and the pulp, though it were large, would be 
tilled with coagulable lymph ; and, even if it were 
thus filled, a bony deposit might not be made ; 
and if it were not, it could not fail ultimately 
to prove injurious to the pulp. But if the space 
should not be filled with lymph, the difficulty would 
be . equally as great, since the pulp would protrude 
through into the vacuum beneath the cap, and neces- 
sarily become diseased, since it would be irritated by 
its contact with, and its pressure against, the sharp 
edges of dentine at the orifice of the cavity ; and it 
may remain thus diseased for a long time, or die at 
once. Thus it is, no doubt, that the great majority 
of failures occur, under this kind of treatment. In 
order to obviate this difficulty, it has been suggested 
that the space under the cap be filled with some 
appropriate substance, as a thick solution of gutta- 
percha and chloroform, or a small pledget of cotton 
saturated with collodion. 

The frequent failures which occur in capping 



EXPOSED PULPS. 255 

pulps, have incited the profession to seek some 
other method of treatment. A vacuum above the 
pulp being objectionable, some suitable material is 
employed as a shield for this, being placed on the 
orifice of exposure, in contact with the pulp; and 
the filling is then introduced without pressure upon 
the point of exposure. There are several substances 
that have been thus employed, the chief of which are 
asbestos, oiled silk, collodion, gutta-percha, Hill's 
stopping, and os artificial. The material for this 
purpose should be a non-conductor of heat, should 
not be subject to decomposition when in contact with 
the pulp, and should present a smooth surface and be 
easily adapted. In shielding a pulp in this manner, 
it is important that pressure be not made upon it; 
and there is not much liability to this, where the 
orifice of exposure is small; but, where it is large, 
much care is required in the introduction and con- 
solidation of the plug. The opinion has been enter- 
tained by some, that the pulp of a tooth will not 
tolerate any foreign substance in contact with it; 
but' facts refute such an opinion. By this kind of 
protection for a pulp, secondary dentine is more 
likely to be developed. 

A very perfect covering for an exposed pulp may 
be made by dropping on it a little collodion or 
solution of gutta-percha, and after the evaporation of 



256 EXPOSED PULPS. 

the ether or chloroform, filling over it. This method 
has the advantage of completely filling and occupy- 
ing the space, and exactly conforming to the part. 
When the exposure is at a large orifice, if the pulp is 
healthy, and the constitution of the patient good, the 
same general course of -treatment may be adopted, 
except that more care and skill will be necessary in 
the performance of an operation. Indeed, it is 
difficult to make a good operation in cases of this 
kind, using for the covering only a soft or flexible 
material. 

A method of operating, that is probably more effi- 
cient than any other, is, to prepare the cavity as 
already directed, place on the pulp two or three drops 
of collodion or solution of gutta-percha, letting it 
partially stiffen, and then over this fit a gold cap as 
exactly as possibly, so that it shall rest on the solid 
dentine jfar enough from the orifice of exposure to 
preclude it from injurious influence on the pulp. On 
this, the filling is introduced as usual, care being had 
not to displace the cap, which, in all such cases, 
should have a seat made for it, formed at the time 
of the preparation of the cavity. 

When the pulp of a tooth becomes by exposure, 
inflamed or diseased, some more special treatment is 
indicated, and usually it is therapeutic. In every 
such case, the treatment will contemplate either the 



EXPOSED PULPS. 257 

preservation of the pulp, when the circumstances 
will warrant; or when they will not, then its 
destruction. The former of course is always to be 
preferred, where practicable. Some of our best opera- 
tors very strongly denounce the wholesale destruction 
of the pulps of teeth, practised by many ; while some 
dentists never attempt to restore them to health at 
all, however slightly diseased. This, as elsewhere 
intimated, is erroneous practice ; for there is no obvi- 
ous reason why the pulp of a tooth may not be re- 
stored from disease to health as readily as other parts ; 
endowed, as it is, with circulation, nutrition, absorp- 
tion, and the distribution of nerves. The particular 
kind of treatment required in any given case, how- 
ever, will be controlled by various circumstances; 
such as the nature and extent of the disease; whether 
it is of chronic or acute type ; and when the irrita- 
tion, or inflammation, is but slight, and is kept up 
solely by the contact of irritating substances, restora- 
tion of the pulp may be effected by a removal of these 
irritating causes, and a protection of the pulp against 
their further influence : in such case, nature, unaided, 
effects the restoration. In default of a vigorous con- 
stitution, the pulp, though but slightly affected, will 
require topical therapeutic treatment ; and meanwhile 
general treatment may be employed to give increased 
tone to the system. In the local treatment, neutral- 



258 EXPOSED PULPS. 

izing agents should be applied first, and afterwards 
such as will counteract and reduce inflammation, 
especially if this is in an active state. But if the 
pulp is in a morbid condition, with retarded circula- 
tion, and a tendency to enlargement, very active and 
stimulating applications will be indicated, and in 
some cases escharotics, such as nitrate of silver, 
chlorid of zinc, and chromic acid, the latter especially 
where there is a tendency to prurient enlargement of 
the pulp. The therapeutic principles embraced in 
astringents, tonics, stimulants, and escharotics, are 
mainly to be relied upon in the topical treatment of 
exposed pulp; but a detailed account of the nature, 
influence and effects of all the individual agents em- 
bodying these principles, and of the respective meth- 
ods of applying them, belongs rather to dental 
therapeutics. 

The length of time requisite for the treatment of 
exposed pulp, will vary with different cases. In the 
case of a recent acute inflammation, the process of 
restoration may be completed in two or three days ; 
while, in other cases, where the difficulty is of long 
standing and of a more complex character, it will re- 
quire from a week to two months. The systemic con- 
dition of the patient also exercises a great modifying 
influence upon the treatment. Leeching and counter- 
irritation of the gums are sometimes resorted to in this 



EXPOSED PULPS. 259 

treatment; but it is rare that any definite beneficial re- 
sult ensues. Depletion of the pulp itself may often be 
practiced with decided success : and it may be accom- 
plished either by puncturing the pulp with a fine- 
pointed instrument, or by excising a small portion of 
it at the orifice of exposure with a very sharp one, 
in either case avoiding laceration of the pulp. By 
this means the distended vessels are relieved ; and in 
many cases, where the difficulty is but slight, imme- 
diately after such relief by puncturing, so soon as the 
hemorrhage has ceased, the tooth may be filled. But 
if the depletion is by excision, time must be allowed 
for the recovery of the incised surface — ordinarily 
from three to ten days. 

A method of treatment of exposed pulps ; first 
introduced to the notice of the profession by Dr. 
Allport ; and one which in his hands has proved quite 
successful; consists in the excision of a portion of 
the pulp at the orifice of exposure, and drawing the 
edges of the incised part together, and inducing their 
union, and in this manner closing the wound, when 
less space is occupied by the pulp than before the 
operation. After securing this result the operation 
of filling the tooth may be performed ; the same care 
being observed, however, as already suggested in cases 
of exposed pulp. 

The formation of secondary dentine, by which the 



260 EXPOSED PULPS. 

orifice of exposure is closed up, has. already been re- 
ferred to ; and it has been suggested that treatment 
to facilitate this process may be instituted. With a 
view to this, temporary fillings are sometimes intro- 
duced ; and irritation of the pulp by frequent slight 
friction, has been adopted ; but the success attending 
this treatment is not very manifest, indeed not definite 
enough to warrant adoption. If a shield of secondary 
dentine is desirable before permanent filling, the best 
method of securing it, is, after seeing that the general 
recuperative power is in the best condition, to place 
in the cavity a temporary filling, of such material and 
in such manner as shall be least offensive to the pulp, 
— perhaps there is nothing better than Hill's stop- 
ping, — and then leave nature to accomplish the work. 
In many cases, especially in young persons, this 
process would be facilitated by an administration of 
bone phosphate. The pulps of the teeth of the young 
are more difficult to treat successfully than those of 
the more advanced in life. 

Destruction of the Pulp. — There are cases in which 
an attempt to restore the pulp, even when recently 
and but slightly diseased, would prove unavailing; 
so feeble is the vitality that it is destroyed at almost 
the first touch. Two cases in apparently the same 
condition pathologically, but in different constitu- 
tions, will, under the same treatment, exhibit very 



EXPOSED PULPS. 261 

different results. A pulp that is highly diseased, is but 
seldom, if ever, under any circumstances, susceptible 
of restoration ; and in such case, of course, devitaliza- 
tion and removal are indicated. This was formerly 
supposed to be an impracticable operation, for two 
reasons : first, because it was very difficult and painful; 
and second, because of the consequences likely to 
ensue. Then, the operation was attempted only on 
teeth having one root, and those of cylindrical form ; 
but now, it is performed successfully on all classes of 
teeth. When destruction of the pulp is decided upon, 
such means should be employed as will effect the 
object promptly and thoroughly. Every thing should 
be entirely removed from the pulp-chamber and the 
canal of the root ; for any remaining portion is liable 
to induce inflammation and suppuration ; and alveolar 
abscess, also, frequently ensues. 

There are two methods of destroying the pulp : the 
one, by an operation; the other, by the application of 
some devitalizing agent. The choice of these methods 
will be governed by circumstances ; such as the tem- 
perament of the patient, the condition of the tooth 
and parts about it, the class of the tooth to be 
operated upon. For patients of a nervous, irritable 
temperament, to whom a removal of the pulp by an 
operation would occasion great pain and a severe 
shock, it would be better to apply some agent to do- 



262 EXPOSED PULPS. 

stroy the vitality of the pulp, and then remove it ; but, 
on the contrary, where there is vigor, a capacity 
of endurance, it is preferable to remove the pulp 
at once by an operation. To accomplish this, there 
are two or three methods of manipulation. In 
the first place, however, by whatever method it is 
removed, it should be fully exposed ; the orifice of 
exposure should be as large as the pulp-chamber, and 
the entrance as nearly as possible on a line with the 
tooth's axis; hence it will be necessary in many 
cases to make an opening into the pulp-chamber at a 
point different from that of the opening caused by the 
decay. For instance, in the incisor teeth, when the 
decayed cavity is small, on the side, near the margin 
of the gum, penetrating to the pulp-chamber, and 
exposing the pulp, the entrance through this opening 
into the canal will be almost at right angles with it ; 
and in such case it would be impossible, through this 
opening, to manipulate freely in the root; and it 
would be necessary to make an opening with a drill 
through the palatal portion of the tooth directly into 
the canal and on a line with it ; which opening should 
be large enough readily to allow of a removal of the 
pulp through it, and of an unimpeded performance of 
all the subsequent operations on the canal of the root. 
After the pulp has been exposed by the proper 
opening, the instrument should be selected for its 



EXPOSED PULPS. 263 

removal. There are different forms of instruments 
for this purpose. Some operators employ the untem- 
pered, four- sided, barbed broach, thrusting it up into 
the canal as far as possible, then twirling it two or 
three times around, and thus wrapping the nerve 
round the instrument ; when both are drawn away 
together. This method always occasions considerable 
pain. Others employ simply the three or four-sided 
broach, thrusting it through the pulp all the way up 
the canal, and thus lacerating it and breaking up its 
structure, so, that it may afterward be removed with- 
out much pain. Another method, and one which seems 
preferable to all others, is as follows : take a very 
fine untempered steel wire, round and smooth, not 
larger than 34 to 36 of Stub's gauge-plate; flatten 
the extreme point, and turn it to an angle of from 
thirty to forty degrees ; place the edge of this against 
one wall of the canal at the point of exposure of the 
pulp ; press it steadily up the canal, with its edge 
bearing against the wall, as far as it will go, and then 
twirl it suddenly round : thus an excision is effected 
near the point of the root, when the pulp with the 
instrument may be drawn away together; or, if not 
thus removed, it may be caught with some fine point, 
and removed with little or no pain. This manner of 
introducing the instrument, too, causes less pain than 
either of the others; for there are no sharp edges or 



264 EXPOSED PULPS. 

points presented in passing the instrument up the 
canal, to cut or lacerate the pulp. In the removal of 
the pulp from the teeth of young persons, care should 
be taken lest the instrument pass entirely through 
the foramen, at the apex of the root; but with adults, 
there is little or no danger of such an accident. 

The directions given here would be quite sufficient, 
if closely followed, for the removal of the pulps of 
the six anterior superior teeth. For the removal of 
the pulps from the bicuspids, the entrance can ordi- 
narily be effected through the decayed cavity. 
Usually, there is some lateral compression of the 
roots of these teeth ; and the canal through the root 
corresponds in its formation, so that it represents a 
mere fissure expanded a little on each side of the 
center. It is often difficult, and requires very deli- 
cate manipulation, to remove all the pulp from these 
fissures : a very fine instrument may be pressed down 
each side, and yet a portion of the pulp remain in 
the center. This difficulty is most fully presented in 
those cases in which there has been an apparent, 
though abortive, effort of nature to produce two roots. 

The removal of the pulps of the molar teeth is a 
more extensive and complicated operation. The pulp 
to be operated upon should be fully exposed, the 
orifice of exposure being made as nearly as possible 
of the size of the pulp-chamber; and the instrument 



EXPOSED PULPS. 265 

to be used, should be such as last described, except 
that it should be much larger, and is to be introduced, 
in the same manner, to the bottom of the pulp-cham- 
ber, and rotated suddenly, so as to cut off the ramifi- 
cations of the pulp into the roots, thus at one sweep 
dislodging the entire body of it without laceration. 
The practice of plunging a large barbed or cutting 
instrument into the pulp of a molar tooth, is barbarous 
in the extreme. The branches of the pulp in the 
roots should be removed in the manner already 
directed for the reinoval of the pulps from teeth of 
single roots. The palatal root is very easily operated 
upon; but, as to the buccal roots, there is frequently 
encountered the same difficulty referred to in speak- 
ing of the bicuspids. Commonly, when a pulp is 
removed in this manner, the wound heals by first in- 
tention, and there is formed a permanent cicatrix. 

Actual Cautery. — Formerly, for destroying tooth- 
pulp, the actual cautery was employed to a consider- 
able extent, and was at one time a favorite method 
with French dentists. This consists in heating a 
wire of proper size to a white heat, and thrusting it 
up the canal of the root to the apex, the object being 
to destroy the pulp the instant the wire comes in 
contact with it. The operation requires much skill, 
and is attended with many difficulties. It is fraught 
with terror to the patient; if the temperature of the 



266 EXPOSED PULPS. 

wire is not at the white heat at time of its insertion, 
the pain of the operation is most intense; it is liable 
to leave the parts in such a condition as often to in- 
duce inflammation and suppuration, which may involve 
the investing membrane and the surrounding parts. 
Besides, by this method, the object is, at best, no 
more successfully attained than by others. 

Potential Cautery. — This term is applied to those 
therapeutic agents which destroy vital tissue by estab- 
lishing a condition incompatible with vitality. Many 
preparations have been employed as topical applica- 
tions to devitalize the pulps of teeth, but only two or 
three to any considerable extent. A consideration 
of the nature, and something of the specific action 
of these agents may not here be out of place : and, 
first, of 

Arsenious Acid. — This has been more used, topi- 
cally, for the destruction of tooth- pulp, than all other 
applications. The first account we have of its use for 
this purpose, dates back to 1836, when it was applied 
by Dr. Spooner, though others claim to have employ- 
ed it at about the same time. The specific action of 
arsenious acid on vital tissue is not well understood. 
It is supposed by some that it forms a compound 
with some element of the tissue, and in this way 
destroys the vitality. 

Any such combination, however, has hitherto es- 



EXPOSED PULPS. 267 

caped detection; and it is certain that if a compound 
is formed, it is not fixed or permanent in its char- 
acter, since the arsenic will be carried to different 
parts of the system, and its specific influence mani- 
fested wherever it goes ; which could not be the case 
if it formed a fixed compound. The more probable 
theory is, that it destroys vitality by its influence on 
nerve tissue ; producing such a change in its structure 
as to arrest its function at once; in reference to the 
action of this agent upon living tissue, much investi- 
gation remains to be made. Animal tissue takes it 
up by imbibition; and it is also absorbed by the cir- 
culation, and conveyed by it, as already suggested, 
throughout the system. Frequently, however, it is 
applied to living tissue under conditions that prevent 
such absorption. It is often employed in the treat- 
ment of carcinoma. In the application of arsenious 
acid to the pulps of teeth, for their destruction, seve- 
ral circumstances are to be considered; such as the 
age of the patient, the constitutional tendency, the 
vascularity of the dentine. Where the vascularity is 
great, the utmost caution is required. The indiscrimi- 
nate use of this agent in the teeth of the young, is 
attended with great risk. Some constitutions are 
peculiarly susceptible of its influence, experiencing 
its effects even in remote parts of the system, after 
its application only to the pulp of a tooth. It is 



268 EXPOSED PULPS. 

absorbed more readily in solution than in solid. It is 
soluble in creosote and most of the essential oils, and 
to some extent in alcohol and water. In many 
cases, when it is applied to the pulp of a tooth, more 
or less disturbance of the periosteum is exhibited a 
short time after — in some instances in a few hours, 
and in others after several days; thus giving evidence 
that it has, by some means, come in contact with the 
periosteum. Its influence on this, will often be 
manifested under percussion, in advance of any other 
symptom. 

Application. — There are two or three methods of 
applying arsenious acid for the destruction of the 
pulps of teeth. The ordinary arsenic of commerce is 
used. It was formerly employed very extensively in 
connection with sulphate of morphia, mixed in equal 
parts, and applied to the pulp with a small pledget of 
cotton, moistened with creosote or some essential oil, 
the former being most frequently used. Alcohol, 
ether, or water may be employed in stead of creosote, 
and in some respects and in some cases would be 
preferable. The pledget of cotton, thus prepared, is 
introduced into the decayed cavity, with the prepara- 
tion in contact with the exposed pulp. Another 
pledget of cotton, saturated with a thick solution of 
gum sandarac and alcohol, or gutta-percha and chloro- 
form, is placed over this in the cavity, to prevent the 



EXPOSED PULPS. 269 

escape of the preparation, or the entrance of moisture 
or foreign substances : any preparation may be used, 
that will accomplish these objects. In the applica- 
tion of the pledget, care must be exercised lest too 
much pressure be made on the pulp, and pain be thus 
produced. In order to prevent this pressure, another 
method has been adopted, which consists in forming 
a cap of lead, placing in it the arsenic, in the dry 
state or with some suitable solvent, and then fitting it 
over the exposed pulp, and retaining it there with a 
pledget of cotton, as above, or with Hill's stopping, 
gutta-percha, or adhesive wax. Thus the preparation 
comes gently in contact with the pulp, and prevents 
any pressure on it. The morphine is used for the 
purpose of diminishing the pain which frequently 
results from the application of arsenic only; but its 
influence for such a purpose is predicated more on 
theory than on practice; for facts prove that, applied 
to living tissue, it produces pain rather than allays it. 
Therefore the more observing and better class of 
practitioners have discarded it. 

Other substances have been mixed with arsenic, 
for the purpose of mitigating or altogether relieving 
the deleterious consequences so liable to follow its 
administration; as, for instance, pulverized charcoal, 
which combined with it in equal parts by weight, 
makes a favorite preparation with good practitioners. 



270 EXPOSED PULPS. 

by some of whom it is claimed that the charcoal 
counteracts the specific effect of the arsenic on parts 
other than those for which it is directly designed. 
But this theory, in the light of any elucidation yet 
given, is very vague. The claim can not be, that 
charcoal is an antidote to arsenic, since facts refute 
it; for if it were, the arsenic of the preparation, when 
applied to the pulp of a tooth, would fail of its effect, 
because the charcoal, being also in contact with the 
pulp, would there, if ever, counteract the poison. But 
this it does not do ; for the pulp is destroyed about 
as readily by this preparation as by arsenic alone. 
And if, when the arsenic and charcoal are thus 
together, no counteracting influence of the latter is 
manifest, much less will there be any when the 
arsenic, escaped from the charcoal, runs riot through 
the tissues, whither the latter can not follow. The 
only probable advantage, then, of this preparation, is, 
that the arsenic is not taken up from it by the tissues 
so rapidly, as when it is applied alone or with any 
thing that is soluble with it; for, when thus applied, 
the whole is very soon dissolved, and taken up by 
the pulp and dentine. But, when combined with 
charcoal or the like, little more of the arsenic is 
absorbed than that which comes in contact with the 
pulp. Hence the conclusion, that the influence of the 
charcoal is mechanical, and not therapeutic. 



EXPOSED PULPS. 271 

This preparation is better applied perfectly dry, 
beneath a lead cap, which should completely close 
the cavity. Any other material that would mix as 
readily with the arsenic, without being soluble, and 
that would not induce irritation when in contact with 
the pulp, would be quite as good for this purpose as 
charcoal. Irritating gases generated in a tightly 
closed cavity, are absorbed by charcoal. 

Cobalt, in which the active principle is arsenic, has 
been extensively used for destroying pulps; but it 
is in no respect superior, and in some respects it is 
probably inferior, to the preparation of charcoal and 
arsenic : it is applied in the same manner. 

The length of time the preparation should remain 
in the tooth, will be determined from the condition of 
the pulp when it is applied, the age of the patient, 
the vascularity of the dentine, the susceptibility of 
the patient to the influence of arsenic, and like cir- 
cumstances. It will usually be from three to twenty- 
four hours. In some cases, a very small particle will 
thoroughly accomplish the work; while in others, a 
much larger quantity may remain in contact with the 
pulp even for a much longer time, without producing 
more than a superficial result. And cases occasion- 
ally occur, in which it seems almost impossible to 
destroy the vitality of a pulp with arsenic. A case 
is on record, in which the pulp was first fairly exposed 



272 EXPOSED PULPS. 

in a superior bicuspid tooth, the health and constitu- 
tion being good, and the temperament sanguino- 
lymphatic; and arsenic with morphine was applied to 
it, directly, five times within ten days, without pro- 
ducing any apparent effect; then an application of 
creosote and tannin was made three or four times, 
during as many days; afterward the tooth was tem- 
porarily filled with gutta-percha; and finally, in ten 
or twelve days, this filling being removed, the pulp 
appeared in a state of perfect preservation and health, 
with all the indications of undiminished vitality. 
Over the exposed point there was placed a non-con- 
ductor, and upon it a filling of gold ; and one year 
after, the tooth presented the appearance of perfect 
life and health, having given the patient no annoyance 
during the whole period. Several similar, cases might 
be cited, were it necessary. 

Hence it is quite obvious that there is a great di- 
versity of susceptibility to the influence of arsenic, 
and that the study of these idiosyncrasies is both in- 
teresting and valuable. The recurrence of injurious 
consequences from the use of arsenic, has induced 
many operators to abandon it altogether. But these 
injurious results perhaps occur always either through 
mal-administration, or from a peculiar susceptibility 
to the influence of the drug; and a superior skill and 
a more accurate diagnosis would avoid them almost 



EXPOSED PULPS. 273 

entirely. After the desired result with arsenic has 
been obtained, it has been thought that antidotes to 
arrest its further operation might be made available. 
The hydrated sesquioxyd of iron is one of the best 
antidotes to arsenic, and has been used in the teeth 
to counteract its injurious effects; but it is of no avail 
here; the arsenic has the start of it, and, indeed, 
would outstrip it, with an equal start. 

From the foregoing in regard to arsenic as an ap- 
plication for destroying the pulps of teeth, the fol- 
lowing conclusions are justly deducible : it is, in gene- 
ral, very efficient; it is a heroic agent*; it should in 
all cases, be used with great caution; in some cases 
it is entirely inadmissible; a free administration of it 
is liable to be followed by bad consequences; and 
skill and care, rather than counteracting agents^ are 
to be relied upon in its application. 

Filling Pulp-cavities and Canals. — After the pulp 
of a tooth has been destroyed, whether by an opera- 
tion or by therapeutic treatment, the part at the point 
of its detachment should, in all cases, before the fill- 
ing is introduced, be rendered healthy; if possible, a 
permanent cicatrice should be formed. In cases. 
however, of good constitution and strong recuperative 
power, where a pulp has been removed by an opera- 
tion, the root may be filled as soon as the hemorrhage 
has ceased; but such cases rarely occur. Generally. 






274 EXPOSED PULPS. 

the part will require treatment; and the character 
and duration of this will be determined by the cir- 
cumstances — as, the vital energy of the system, and 
the method employed for the pulp's destruction. 
When this has been effected by an operation, the 
wound produced by the excision is restored to sound- 
ness much more readily than when by an application 
of arsenious acid, and less topical treatment will ordi- 
narily be required; indeed, in many such cases there 
will be nothing else required, than to keep the canal 
well cleansed, so as to obviate any irritation that other- 
wise might be'induced by decomposition. When the 
pulp has been destroyed by arsenious acid, more en- 
ergetic treatment is usually demanded; for then there 
is always a greater or less disposition to slough or dis- 
charge through the tooth; which must of course be 
entirely abated, before the operation of rilling is at 
all admissible. In the treatment of this condition, 
the canal should be kept perfectly clean by frequent 
syringing; floss silk, moistened with creosote and tan- 
nin, should be introduced to the extreme part of the 
cavity or canal, and should be changed every twenty- 
four hours, the cavity being thoroughly washed each 
time. It will be necessary, in many cases, to continue 
this treatment for several days. In order to determine 
whether the condition is such as to admit of the fill- 
ing, the floss silk should be removed after a sufficient 
time is supposed to have elapsed, the cavity thoroughly 



EXPOSED PULPS. 275 

cleansed and dried, and a portion of dry floss silk or 
cotton introduced loosely into the canal. Then close up 
the decayed cavity with adhesive wax, gutta-percha, or 
some other substance that will effectually exclude the 
moisture ; let it remain thus from twelve to twenty- 
four hours; then open the cavity, and withdraw the 
silk or cotton, and if this is found free from moisture 
and odor, the tooth is ready to be filled. 

The treatment just described will be sufficient for 
all cases in which the pulp has been destroyed by the 
operator. But teeth whose pulps are already dead, 
would seem to be less difficult of treatment and fill- 
ing; yet such is not the case; — indeed, the therapeutic 
treatment of these is usually more protracted, and 
their diseased condition less easily controlled ; and 
this because of the fact that the decaying pulp, re- 
maining in the canal, becomes very offensive and 
irritating to the living parts adjacent, in which it 
induces a chronic diseased condition, frequently in- 
volving the dentine along the walls of the canal in 
decomposition. 

A classification of these teeth, based on their con- 
ditions, might be somewhat auxiliary to a further 
examination of this subject; and the following will 
probably embrace them all : — 

1st. Those whose pulps are dead, but their attach- 
ment and adjacent parts alive and healthy. 



EXPOSED PULPS. 



2d. Those predisposed to disease. 

3d. Those already diseased, either discharging 
acrid matter through the root, or exhibiting inflam- 
mation of the periosteum. 

4th. Those having alveolar abscess. 

Sound or slightly decayed teeth are sometimes 
found with dead pulps. This condition may be pro- 
duced in various ways : by blows, or by any force 
that will partially loosen the tooth; by undue press- 
ure in rilling; by excessive sensitiveness of the den- 
tine, even where the decay is not extensive; and, 
sometimes, by a filling of the tooth when it is in an 
unfit state for the operation. Ordinarily, in cases in 
which the pulp is dead before its exposure, and there 
is no abscess from the root or periosteum, the pulp- 
chamber may be opened, and the remains of the pulp 
removed. The canal should then be cleansed out, 
and floss silk moistened with creosote, introduced and 
permitted to remain from one to six hours; when it 
should be withdrawn, the pulp-cavity and the canal 
again thoroughly cleansed, when, if there is no dis- 
charge of pus through the root, it may be filled. 
The fact that the dead pulp is inclosed in its chamber 
without producing irritation is evidence that there is 
no secretion of pus. Occasionally, where the pulp 
has died from exposure, the living part immediately 
adjacent will present a healthy condition, and there 



EXPOSED PULPS. 277 

will be no discharge; such cases should be treated in 
the manner just described. In operating on teeth 
already dead, more delicate manipulation is requisite 
to prevent irritation, than on those in which the pulp 
is destroyed by the operator. In very many cases of 
dead teeth, where there is not a state of actual dis- 
ease, there is a strong predisposition to it; and in 
these cases, the preparation of a cavity, or the intro- 
ducing and condensing of a filling, may produce in- 
flammation of the periosteum. When such a condition 
is recognized, several sittings may be required to 
complete the operation. But it is not always easy to 
recognize such a predisposition; yet, whenever it is 
suspected, it is well to press the investigation, which 
may be. guided by the following rules: ascertain 
whether the tooth experiences a different sensation or 
any pain, under percussion in any direction; whether 
periostitis has ever existed in that or in a contiguous 
tooth; whether the parts adjacent to the tooth are in 
a healthy state; whether there is a general inflamma- 
tory diathesis, or an enfeebled condition. These are 
the prominent points in an examination of this kind. 

Where this predisposition exists, it may be coun- 
teracted by general or local treatment, according as 
it depends on general or local causes; but in even- 
case, this treatment should be very careful, and it 
will, in some instances, have to be protracted. Iu 



278 EXPOSED PULPS. 

those eases, where there is a discharge through the 
root of the tooth, such treatment should be adopted, 
as will most speedily and effectually suppress it; and 
if it proceeds from a remaining portion of the pulp-tis- 
sue near the point of the root, this should he removed, 
and such application made as will prevent a recur- 
rence of the discharge, and assist the part to recover 
its health. The discharging surface may be broken 
up by cutting it away with an instrument, or be 
destroyed with an escharotic — either nitrate of silver, 
creosote, or chlorid of zinc, in the use of which, seve- 
ral applications will, in many cases, be necessary. 
From their action, the secreting surface is destroyed, 
healthy granulations spring up, and a healthy condi- 
tion is established. 

The discharge should be wholly suppressed before 
the tooth is filled ; otherwise, alveolar abscess would 
be speedily formed. In cases where there is periosti- 
tis, it must be subdued before the tooth will tolerate 
the operation of filling. To attain this end, the treat- 
ment to be adopted will be dictated by the nature of 
the causes which operate to induce the disease. 
General treatment will be indicated where there is a 
constitutional condition favorable to the local affection ; 
but where there is no such general predisposition, the 
treatment should be chiefly local, and may consist of 
the following or similar appliances : depletion, either 



EXPOSED PULPS. 279 

by leeching, cupping, or scarifying the gums; or 
counter-irritation, either by scarifying, or by the ap- 
plication of highly stimulating lotions. Counter- 
irritation may be produced, also, by making a deep 
incision in the gum opposite the tooth affected, and 
introducing a little flock of floss or cotton, saturated 
with creosote, which is to be kept in place till the 
inflammation of the periosteum is allayed; which will 
be effected in from one to five days. The silk or 
cotton should be changed every day, till the restora- 
tion of the tooth to health is affected, when it is to be 
removed, and the wound permitted to heal. Mild 
stimulating applications to the gums in the immediate 
vicinity, to increase the circulation, will, in some 
cases, be all that is required. A vapor bath, or warm 
water applied to the part, is often beneficial; and, in 
some cases, a continued application of cold, by means 
of ice-water, will subdue inflammation of the perios- 
teum. Indeed, any antiphlogistic treatment that can 
be adopted advantageously, may be employed in 
periostitis. 

The periostitis of teeth whose pulps are dead, 
commonly has its origin at the point of the root, from 
irritation induced in the beginning by the dead and 
decomposing pulp and other matter at that point. In 
many instances, the inflammation is not confined to 
the root of the tooth on which it began; but it will 



2S0 EXPOSED PULPS. 

extend to the alveolus, the gums, and the periosteum 
of the neighboring teeth. Whenever the existence 
of this disease is suspected, and yet not very appa- 
rent, as is often the case, the examination should be 
very thorough. In some instances, percussion of the 
tooth at one particular point and at a certain angle, 
will produce pain; whereas, striking on any other 
part of the tooth, or at any other angle, will cause 
none at all. By an exercise of care and discrimina- 
tion, the exact point of disease, even if confined to 
a small space, may be ascertained. For instance, if 
striking on the labial surface of a central incisor 
near the point, produces pain in the socket, while on 
any other point it does not, the place of the inflam- 
mation is the anterior portion of the root, at or near 
its point. By such means, the skillful and discern- 
ing will be enabled to form a tolerably accurate 
opinion as to the extent and location of periostitis 
in all cases ; and this is an important consideration ; 
for, if inflammation is found confined to a small por- 
tion of a root, the treatment, if local, should be as 
near that point as possible. 

Inflammation of the periosteum may sometimes be 
induced by the presence of foreign substances forced 
down between the free margin of the gum and the 
neck of the tooth, which have remained there till 
they have become vitiated,- so as injuriously to affect 



FILLING ROOTS. 281 

the gums and periosteum. A deposit of salivary cal- 
culus sometimes produces inflammation of the gums 
and periosteum. Teeth otherwise healthy are, in 
some instances; thus affected ; though those which 
have lost their internal vitality, are much more liable 
to such disease. 

Preparing the Teeth and Roots for Filling. — After the 
tooth has been brought to a healthy condition, the de- 
cayed cavity is first to be excavated and made of pro- 
per form, the pulp-chamber to be shaped, and then the 
canals and the roots to be prepared for filling. For 
the preparation of decayed cavities here, the directions 
given on that subject hitherto, will be quite sufficient. 
In the formation of the pu]p- chamber, the abrupt 
projecting portions of dentine should be cut down ; 
and if there is any decomposition of this, it should 
be removed. The pulp-chamber may be, when it is 
excavated, of a general retaining form, or there may 
be retaining points made within it at proper situa- 
tions. In the preparation of the canals in the roots, 
some operators do nothing more than cleanse them 
out thoroughly. Another method is, to pass fine 
bur-drills into them as far as practicable, thus making 
the opening of the same size all the way ; or to scrape 
out the canal with a fine No. 10 excavator. Very 
fine, delicate instruments are' required for cleansing 
out and forming the canals'; and they should be quite 



282 



FILLING ROOTS. 



elastic and of low temper. A set of instruments for 
forming the canals in the roots of the teeth have been 
devised and made by Dr. C. Palmer. These are of 
such forms and sizes as to be suitable for every 
case. They are represented in Fig. 54. Before 

Fie. 54. 




the introduction of these instruments, the method of 
forming these canals was by the use of a three or 
four-sided broach, tapering to a sharp point, and in 
inclination corresponding as far as possible to that of 
the canal. This instrument was employed to enlarge 
the canal, and give it a regular shape ; a variety 
should be at hand, so that one of the proper size and 
taper can be selected. In cleansing and forming the 
canal, care is necessary to prevent the instrument 
from passing entirely through the point of the root. 



FILLING ROOTS. 283 

Such an accident is not very liable to occur with the 
tapered broach ; but with the miniature excavator or 
barbed wire, it is, — especially in the teeth of the 
young, where the foramina through the roots are 
large ; and it is especially liable to happen to the 
incisors, the canine, and the palatine roots of the 
superior molars. But, after the complete develop- 
ment of the teeth, there is no excuse for an accident 
of this kind ; for then there is an abrupt contraction 
of the canal near the point of the root, which may 
always be detected by a careful introduction of the 
instrument. 

The decayed and pulp-cavities and the canal all 
being thus prepared, are now ready to receive the 
rilling. For filling the root, there are several 
methods; one of which is, to prepare small strips of 
gold, of two or four thicknesses of foil, take these on 
the point of an instrument, and pack them into the 
root, in successive folds, till the canal is full. Another 
method is, to take small portions of gold, and pack 
them in, one on another, till the canal is full. 
Another is, to take strips of from two to four thick- 
nesses, and from one to two lines wide, and roll them 
on a fine broach in such a manner as to make a cone- 
shaped block, a little longer than the depth of the 
canal to be filled, and of the same taper ; quite a 
number of these blocks will be required for any given 



284 FILLING ROOTS. 

case, of various sizes, lengths, and densities ; the 
longest, largest, and least dense should be first used, 
the last requiring to be of less size and greater density. 
These cones may be made as dense as desirable by 
rolling them firmly between the thumb and fingers, 
after having taken them off the broach. They are 
then introduced with the plugging pliers, and passed 
up as near to the point of the root as is consistent with 
safety. In some instances, there is danger of thrust- 
ing them through the point ; and, in order to prevent 
this, the end of the first block introduced may be 
made so large that it will not pass through, even 
when forced up ; or, what is probably better, a very 
small round pellet of gold may be forced up the canal, 
as near to the point of the root as admissible, and 
this serves as a foundation for the subsequent portions 
of gold, and prevents them from passing too far up. 
The cone-shaped blocks may be introduced and con- 
solidated with an instrument of the same general form 
as the canal, but much smaller. This kind of instru- 
ment should be made of untempered steel; though 
some operators make them of whalebone, to prevent 
breaking off in the canal, — an unnecessary precaution, 
since no skillful operator would ever break off a low- 
tempered, well-polished, properly-formed instrument 
of this kind. After a block is placed in the cavity, 
the instrument is thrust in by its side, thus consoli- 



FILLING ROOTS. 



285 



dating the gold to the side of the cavity. Thus, the 
blocks are successively introduced and consolidated, 
till the canal is filled. It is better so to arrange as to 
introduce the last portion of gold near the center of 
the canal, rather than at the side. ' The last blocks 
introduced should be stiff and dense, that they may 
be thrust in with considerable force. The method of 
filling canals at present employed by many, is in the 
use of the filling instruments invented by Dr. C. 
Palmer, represented in Fig. 55. There is a variety 



Fig. 55. 




in size and somewhat in form, so that in all positions 
they will readily enter the canals and effectually con- 
solidate the gold, which is introduced in small cone- 
shaped pellets, loosely rolled, so that they may be 
thoroughly consolidated. * 

Another method of preparing gold for filling roots 
is, to take the pure metal, and roll it down, on a 



286 FILLING ROOTS. 

good rolling-mill, as thin as possible, keeping it well 
annealed ; and of this, form the cones, and introduce 
them as already directed. Made in this way, they 
are stiffer, and fill up much more rapidly, than when 
made of foil. They are to be condensed in the same 
manner. Where the canal has been formed with a 
tapered broach, it may be filled with a gold wire, 
made of the same size and taper of the broach ; this 
wire may be cut off at the orifice of the canal, or left 
protruding more or less into the decayed cavity, and 
be covered up with the filling. When a lost por- 
tion of the form of a tooth is to be restored, such 
projecting wires may be made very valuable as 
anchorages. 

Some other substances have been thought quite as 
suitable for filling the roots of teeth as gold. Lead 
has been employed for this purpose; but the principal 
difficulty with this is, to get it into such a condition 
as to be used with facility; but, if as completely 
introduced, it would probably answer the purpose 
quite as well as gold. Tin foil is also used, and, 
under favorable circumstances, with success. Some 
experiments, too, have been made with plaster of 
Paris and similar substances, for filling roots and pulp 
cavities'; but with what success, it is not ascertained 
— some claiming instances of success, and others re- 
porting, in every instance, failure ; so that there are 



FILLING ROOTS. 287 

not sufficient data to warrant the adoption of plaster 
or any* similar substance in practice. 

In cases in which there is liability to irritation, 
the operation of filling a root is quite enough' for one 
sitting; and in any case, not more than three roots 
should be filled at one time. The filling of a large 
pulp-cavity will occupy one sitting, and that of the 
decayed cavity, another. When a respite is thus 
had between the filling of the pulp-cavity, and that 
of the decayed cavity, the former should be dressed 
down perfectly solid and smooth, so that no moisture 
may penetrate it; and then, when the latter is to be 
introduced, the surface of the former should be rough- 
ened by being cut up with a sharp instrument, or by 
being indented with small retaining pits, so as to lay 
hold of and fasten the last filling. From one to four 
days should intervene between the different divisions 
of the operation. The filling of the decayed cavity 
is to be performed according to the directions already 
given. When inflammation ensues on an operation 
of this kind, recourse is had to the treatment already 
described for preventing, counteracting, or reducing 
inflammation. 

Some experiments have been made to test the 
effect of restoring the parts to health, forming a cica- 
trice at the point of the root, cleansing this out, fill- 
ing the pulp-cavity and the cavity of decay, and 



288 FILLING ROOTS. 

leaving the canal unfilled ; and it is maintained that 
this method will, in favorable cases, answer the pur. 
pose quite as well as that of filling the root, and 
incur less risk. The treatment will be such as 
already described for the restoration of diseased 
roots ; all discharge through it must be suppressed, 
and all foreign substances liable to decomposition, 
removed from the canal, so that there may be a 
complete restoration before it is closed. 

Oftentimes, when a tooth has been filled without 
filling the roots and pulp-chamber, if the pulp be 
dead, or if the pulp afterward dies, the chamber 
becomes the receptacle of a very vitiated and acrid 
material, the retention of which will almost invariably 
produce irritation. In all such cases, an opening 
should be made for the escape of the offensive matter. 
This is clone, if the filling is not to be removed, by 
passing a small drill into the pulp-chamber or canal, 
just above the filling, as close as possible. The handle 
of the drill should be depressed, so as to give the 
opening a downward inclination from within outward, 
and thus favor the escape of any secretion. 

In the superior molars, this opening may be made 
through the masticatory surface; it may, sometimes, 
be in the depressions on the crown surface, even 
though there be no filling. In incisors, it is made 
through the palatine portion of the crown. It is bet- 



FILLING ROOTS. 289 

ter, however, in all cases, to make an opening of this 
kind through the neck of the tooth, just under the 
free margin of the gum, since here foreign substances 
are not so liable to be crowded into it, as where it is 
through the masticatory surface. In cases in which 
it is obvious at the time of filling the tooth, that such 
an opening will be required, it is better to make it 
before the filling is introduced, as follows : first, pre- 
pare the decayed and pulp-cavities for filling; then 
drill through the neck of the tooth, into the canal, to 
the extreme part of the pulp-chamber; and finally, 
introduce into this' hole, its entire depth, a piece of 
smooth steel wire, such as will closely fit, leaving it 
exposed through the decayed cavity — and if it is not 
enough exposed when introduced, the tooth-bone may 
be cut away about it, till it is fully exposed; when 
the decayed and pulp-cavities are filled in the usual 
manner, and condensed solidly against the wire. 
After the filling is finished, the wire is withdrawn, 
leaving a smooth, continuous opening for the escape 
of any secretion that may collect within. When the 
opening into the canal is not made till after the tooth 
is filled, there is liable to be a space between it and 
the filling that will receive and retain fetid matter, 
which may become very offensive. This method of 
treatment is, however, always to be deprecated, and 
should never be employed except as a last resort, or 

T 



290 DENTAL PERIOSTITIS. 

in cases where it is impossible to command the time 
and opportunity for the proper treatment ; and even 
then it is better to make the opening and entrance 
into the chamber and canal just as though it were to 
receive immediate treatment; for in a great many 
instances, the opportunity for that may soon occur. 

DENTAL PERIOSTITIS. 

This affection of the investing membrane of the 
roots of the teeth, is of frequent occurrence after the 
death of the pulp ; but rarely if ever before. In- 
flammation of this tissue in its manifestation, is modi- 
fied by the anatomical structure of the parts. 

"Whether there be two membranes in the alveolar 
sockets, the one lining the walls of these, and the 
other investing the roots of the teeth, is not a matter 
of importance, so far as the nature and treatment of 
this affection is concerned. This condition of the den- 
tal periosteum, is induced by such irritating causes 
as would produce inflammation in other tissues. 

The first indication of approaching difficulty in this 
tissue, is a sense of slight fullness, which invites con- 
tact, and even pressure from the opposing teeth; 
such pressure affording a rather pleasurable sensation, 
and seeming relief. 

This condition is brought about by determination 



DENTAL PERIOSTITIS. 291 

of blood to the part, and the surroundings being such 
as to prevent free expansion of the capillaries, and 
other small vessels, ramifying this membrane, these 
walls are pressed upon in proportion to the force of 
this determination. 

This effort at expansion will occasion, especially in 
those teeth having very conical roots, quite a per- 
ceptible elongation, and this more particularly occurs 
when active inflammation supervenes, which is the 
sequence of the state of irritation, to which reference 
has just been made. 

After active inflammation has occurred, pressure or 
percussion upon the affected tooth, usually causes 
great pain; to such an extent, that sometimes the 
slightest contact even by the tongue is intolerable. 

This condition varies much in degree, in different 
cases, dependent largely upon the predisposition, and 
susceptibility to exciting causes of irritation and 
inflammation, together with the character of these 
exciting causes, whether concentrated in action to a 
mere point, or more extensive in their sphere of 
operation. 

Oftentimes only a very small portion of the peri- 
osteum of a tooth will be affected ; it may be confined 
to the immediate vicinity of the point of the root, or 
to one side, or to the periosteum near the margin of 
the alveolus and the border of the gum. 



292 DENTAL PERIOSTITIS. 

Indeed, so circumscribed is this affection often 
found, that the periosteum on one side of a root, will 
pass through all the successive stages of inflammation 
to suppuration and destruction, without that upon the 
opposite side having undergone anything more than a 
slight irritation, if even that. In such cases the 
vitality has sufficient power to hold the disease at 
bay, and confine it to the immediate point of attack. 

When there is a systemic predisposition, the local 
exciting causes will sooner and more vigorously at- 
tack. Always when the pulp of a tooth is devitalized, 
the periosteum is more liable to disease, and perhaps 
for several reasons. In almost all cases there are 
irritants at hand, that did not exist before ; and the 
periosteum is either enfeebled, and consequently less 
resistant, or the demand upon its function greater 
than before, in view of its being the medium of 
connection, between the normally vital tissue and 
that which is devitalized, or at best, its life very 
much impaired, and when the latter condition exists, 
the nourishment received by the cementum and den- 
tine is wholly through the periosteum. In these facts 
doubtless are to be found the cause of the greater 
susceptibility of the dental periosteum to disease, after, 
than before the death of the pulp. 

The exciting causes of this affection are to be found 
in the acrid debris of the dead and decaying pulps of 



DENTAL PERIOSTITIS. 293 

the teeth, passing either in a fluid or gaseous state, 
through the foramen at the point of the root, and 
there coming in contact with the periosteum, and in 
various deposits, calcarious and others, insinuated 
beneath the margin of the gum, encroaching upon 
and irritating the periosteum. 

It is also sometimes occasioned by an extension of 
disease from some other point. As an illustration of 
this, in susceptible cases, the periosteum of one tooth 
may become affected, by the action of some local 
irritant, and two or more of its neighbors become 
affected by extension of the inflammation. 

Some medicinal agents act specifically upon the 
dental periosteum, inducing a very painful condition, 
thickening of the tissue, and elongation of the teeth. 

Mercurials present an illustration of this class of 
agents. The precise condition produced in the dental 
periosteum in mercurial ptyalism is perhaps not clearly 
comprehended. It is more than simple inflammation. 
It is not modified or controlled by the same remedial 
treatment. It attacks the periosteum of living teeth, 
as readily and with quite as much violence as of those 
which are devitalized. Alveolar abscess is not a 
common result of this affection of the periosteum. 

Treatment. — The treatment of dental periostitis, in 
its details, will be governed by the attendant con- 
ditions, such as systemic predispositions, the vital 
force, and the local causes, and their peculiarities. 



294 DENTAL PERIOSTITIS. 

Systemic treatment should have for its object, the 
removal or counteracting of predispositions, and the 
abatement of the determination of blood to the part 
in question, by inviting it to other parts, by their 
stimulation, and by introducing into the system such 
agents as will tend to allay excitement in the affected 
part, and induce, so far as possible, an equilibrium of 
circulation throughout the system. 

The local treatment must also be wisely and faith- 
fully attended to. The principle applicable to the 
treatment of inflammation in any tissue is that to be 
employed here. It will be remembered, however, 
that there are many medicinal agents which possess 
very desirable properties, that are still totally inef- 
ficient, because of a want of adaptation. We have, 
however, at our command some very efficient reme- 
dial agents, for the treatment of this affection, and 
the list is being constantly enlarged. 

We propose here to consider rather the principles 
involved in the treatment, than details for special 
cases. 

The causes producing and influencing the disease, 
should always be fully apprehended, immediately after 
which, the following points should receive attention : 
First, remove all irritants ; this will embrace the re- 
moval of the dead pulp, and all the debris from its 
chamber, and from the canal in the root, or roots, and 
rendering them perfectly free from all offensive ma- 



DENTAL PERIOSTITIS. 295 

terial, and keeping them so ; and the removal of all 
deposits that may be upon the teeth, and especially 
those that may encroach upon the gum, or the alveolus 
and periosteum at or beyond the neck of the tooth ; 
and the removal of all injurious and useless teeth and 
roots in the vicinity. 

And, secondly, relieve the congestion of the affected 
part, in some or all of the following ways : either by 
systemic influence as already suggested, or by coun- 
ter-irritation, producing determination to a neighbor- 
ing part, and thus relieving the affected part, or by 
depletion from the gum immediately opposite the seat 
of the affection. 

Counter-irritation may be effected by scarifying the 
gum, or by the application of some irritating agent, 
such as tincture of capsicum, tincture of iodine, and 
cantharides. An excellent preparation of the latter, 
denominated cantharidal collodion, has recently been 
prepared, and introduced to the medical profession. 
This preparation when applied to the gum acts 
promptly and efficiently in almost every case of acute 
dental periostitis ; it produces desquamation upon 
the surface of the mucous membrane where it is 
applied. 

Depletion, with many, is a favorite method of treat- 
ment, and often productive of very good effects. Two 
or three methods of accomplishing this are employed. 



296 DENTAL PERIOSTITIS. 

Simple scarification of the gum, cutting it more or less 
deeply, will secure sufficient hemorrhage, especially 
if the gums are quite vascular ; when this fails, cup- 
ping, or the artificial leech, may be employed ; but 
the natural leech is the most efficient means of local 
depletion, in this treatment; and every dentist should 
always have these at command, and be familiar with 
their use. The application of a leech in very many 
cases will, in a very short time, subdue the most 
violent attack of acute periostitis. 

In the treatment of this affection, hyperdermic 
injections give promise of most desirable results; for 
this purpose, the solution of morphine, or tincture of 
opium from ten to twenty drops, may be injected, 
with a proper syringe, beneath the mucous membrane, 
when the pain would be found to subside in a few 
moments, and the severest symptoms be abated in a 
few hours. 

In all cases of periostitis, the sooner it can be 
brought under proper treatment after the attack, the 
more easily will it be subdued. 

In cases of longer standing where the affection has 
assumed a chronic form, the membrane more or less 
thickened and indurated, and a persistent soreness of 
the tooth affected, heroic and persevering treatment 
will be required to overcome the difficulty; in the 
great majority of cases, however, the result is the 



ALVEOLAR ABSCESS. 297 

formation of alveolar abscess, rather than the con- 
dition just referred to; a description and treatment 
of which will next receive consideration. 



ALVEOLAR ABSCESS. 

Alveolar abscess is a result or consequence of per- 
iostitis, and consists of a pus secreting sac, on the 
root, usually at or near the point, but sometimes upon 
one side. The secretions of these sacs differ in 
character, according to the different conditions of the 
parts together with systemic influences. Sometimes, 
the discharge from these sacs is through the root ; 
sometimes from between the tooth and alveolus ; and 
sometimes, directly through the alveolus and gums. 
There are occasional cases in which the discharge 
will be at a very considerable distance from the 
point of secretion ; but, in such cases, the secretion 
always follows some natural avenue that affords a 
facility for its passage — as, for instance, along a 
suture. There are cases recorded where the issue 
from an abscess of the central incisor was near the 
posterior portion of the hard palate ; and, in these, 
the channel of the pus lay along the suture of the 
palate bones. Sometimes, the opening from an ab- 
scess of the first or second molar will be opposite the 
bicuspids on the buccal portion of the gum. Alveolar 



298 ALVEOLAR ABSCESS. 

abscess is exceedingly variable in character, according 
to the constitutional peculiarities and susceptibilities 
of the patient, the condition of the parts immediately 
adjacent, and, to some extent, the cause which has 
produced it. In a good constitution, after an abscess 
is formed, it will discharge healthy pus. Occasion- 
ally, yet very seldom, does nature alone effect a per- 
manent cure. In constitutions of a cachectic dia- 
thesis, alveolar abscess is liable to constant discharge 
of an unhealthy pus, or purulent acrid matter; and 
the parts about it are usually in a diseased condition. 

The cases in which alveolar abscess is most likely 
to occur are those of a manifest inflammatory diath- 
esis, or those in which there is considerable local 
inflammation, from some local exciting cause. In 
the cases of constitutional predisposition, the abscess 
after a time assumes a chronic character, constantly 
secreting and discharging pus, but does not usually 
cause much pain, though the tooth from which it 
proceeds will experience some soreness and an uneasy 
sensation. In the acute forms of it, however, there 
will be intense pain. In some cases, the sac will be 
formed without much irritation of the surrounding 
parts ; while in others, irritation and inflammation will 
extend to parts more remote, especially if there are 
any irritating agents at work. 

Usually, the sac is found at the point of the root ; 



ALVEOLAR ABSCESS. 



299 



but, sometimes, it is located on the side, the point 
remaining comparatively free. In the molars, par- 
ticularly the superior ones, the sac will frequently be 
found in the bifurcation, often occupying the entire 
space between the roots. When it is on the point of 

Fig'. 56. 




one of the roots, this is usually the palatine. Fig. 56 
represents the position of the sacs on the roots of the 
different teeth. 

Treatment. — The treatment of alveolar abscess will 
be governed by the constitution of the patient and 
the condition of the part affected ; a case of recent 
origin will yield much more readily than one of long 
standing. When a case has assumed the chronic 
form, and the surrounding parts have become impli- 
cated in the diseased condition, a restoration to 
health is often very difficult. Indeed, till within a 
few years, the removal of alveolar abscess was 
thought to be, as a general thing, wholly impracti- 
cable. But, by the treatment now employed, this 
affection is readily eradicated, unless the parts in the 



300 ALVEOLAR ABSCESS. 

immediate vicinity are very much involved. In 
some cases, the sac on the point of the root is verv 
large, and absorption has taken place, to accommo- 
date it ; in such instances, the sac being destroyed, 
the space occupied by it will be filled up with a 
healthy tissue. In young persons, when an abscess is 
formed on the point of a root, especially in the single- 
root teeth of the superior maxilla, the discharge is 
frequently through the tooth, in consequence of the 
large size of the foramen at the point of the root; 
and generally, in such cases, the local treatment may 
be made through the canal. Sometimes the dis- 
charge is between the root and the wall of the alveolus. 
More often, however, especially in persons over 
twenty-five years of age, the discharge is through 
the alveolus and the soft parts to the surface, by the 
shortest course. 

When an alveolar abscess is influenced by any 
constitutional derangement, general treatment must 
be resorted to, such as the condition indicates. The 
local treatment always demanded, is such as will 
break up and destroy the secreting sac. This is 
effected either by surgical or by therapeutic treatment, 
and frequently in chronic cases, by both together; 
but, in the great majority of acute cases, therapeutic 
treatment alone will be sufficient. In order to break 
up an abscess by an operation, it must be easy of 



ALVEOLAR ABSCESS. 301 

access ; and it is very seldom that an operation of 
this kind can be performed tnrough the root of a 
tooth ; but, fortunately, in almost all those cases 
where the discharge is through the root, therapeutic 
treatment alone will answer the purpose. When the 
point of discharge is on the gum opposite the secret- 
ing sac, a sharp-pointed bistoury should be used, and 
the canal of discharge sufficiently opened to admit 
the free use of the instrument at the seat of the 
disease. Then the secreting sac should be dissected 
from the point of the root, and its connection with the 
circulation severed as completely as possible, thus 
cutting off its supply. After this, if the case is a 
favorable one, nature may be left to accomplish the 
work ; in which case, the broken up sac will be thrown 
off, healthy granulations developed, and the parts 
restored to complete health. In other cases, how- 
ever, after an operation, nature unaided will not 
complete the cure; but such therapeutic treatment 
must be resorted to, as the circumstances seem to 
require. In some cases, the opening through the 
alveolus will require to be enlarged ; and this part of 
the operation requires great care. All detached 
particles of bone should be removed from the opening, 
since, if permitted to remain, they would produce 
irritation and tend to increase the difficulty. 

When the therapeutic treatment is applied through 



302 ALVEOLAR ABSCESS. 

the root, the canal is to be cleansed of all foreign and 
detached matter, and opened freely through to the 
point; and, if the discharge is very fetid, some dis- 
infectant should be used, than which perhaps nothing 
is better than diluted creosote, since a fetid condition 
keeps up irritation. The cleansing of the root may 
be accomplished by injection of chlorid of sodium; 
after which, the agent to act on the disease at its 
seat, is to be introduced. Of this agent, there are 
various kinds employed, the chief of which are 
chlorid of zinc, nitrate of silver, and creosote, the first 
being applied in the solid, and the latter two in the 
liquid state — though the nitrate may be employed in 
the solid form. The method of using the chlorid of 
zinc is, to pass it in small portions up the canal, on a 
piece of silk; with a fine probe, entirely through the 
point of the root ; which process should be repeated 
every twenty-four to forty-eight hours, as the case 
may indicate. After this, during two or three days, 
floss silk, moistened with a mild solution of creosote 
and tannin in alcohol, should be applied daily; and 
then clean silk or cotton may be worn in the canal, 
changed every day, for three or four days, or till it 
is manifest that there is no longer any discharge, and 
that the parts are in a healthy condition. If nitrate 
of silver, in solution, or creosote is used, it should be 
absorbed into a piece of floss silk, and passed through 



ALVEOLAR ABSCESS. 6\J6 

the root in the manner already described. The nitrate 
is more prompt of action than creosote, and will ac- 
complish a specific object in a shorter time. Either 
of these solutions may. by the use of the syringe, 
be very effectively thrown through a root in the 
following manner : fill the orifice of the canal with 
gutta-percha ; drill through it a hole large enough to 
receive tightly the point of the syringe ; and then, 
charging with the solution, inject it through the root ; 
and, in cases where there is an opening through the 
gum, the injection may be forced round through this. 
The condition of the parts will indicate how long this 
kind of treatment should continue. Ordinarily, when 
the discharge is entirely through the gum, the bistoury 
should be used to enlarge the opening. In many 
cases, therapeutic treatment alone will accomplish the 
object; and, when the opening to the sac is large and 
direct, the therapeutic agents may be introduced 
through it directly to the seat of disease. If nitrate 
of silver, in solution, or creosote is used, it should be 
introduced to the point of affection on a pledget of 
cotton or floss silk, as heretofore directed ; or if, as is 
preferable, chlofid of zinc or nitrate of silver in solid, 
it should be passed through the opening into contact 
with the sac. This treatment should be kept up till 
the indications are fulfilled. 

In the treatment of abscess of the inferior maxilla, 



301 ALVEOLAR ABSCESS. 

much difficulty is often experienced from a want of 
free egress for the secretion : while, in the superior 
teeth, the pus may frequently escape through the 
tooth by gravitation ; this force, in the inferior jaw. 
increases the difficulty. The sac being usually 
formed on the point of a root, the secretion then 
rests at the bottom of the socket, and is frequently 
pent up there till it finds an outlet through the gum. 
somewhere between the point of the root and the 
neck of the tooth. It is, in many instances, very 
difficult to get an ope nng as low down as the point 
of the root, since the buccal attachment to the gum 
is usually quite above that point, particularly in the 
case of the molars and second bicuspids. Very sel- 
dom, if ever, can a secreting sac on the root of an 
inferior tooth be destroyed by treatment applied 
through the canal of the root. Some are accustomed 
to make a vertical incision of the sum, as low as the 
point of the root, and perforate the alveolus, and 
treat through this channel, as already described. 
Owing to the disadvantage above mentioned, much 
more energetic treatment is necessary to attain suc- 
cess with an abscess of the inferior than with that 
of the superior teeth. 

In the great majority of cases, where one half or 
more of the periosteum of a root is involved in 
abscess, the indications certainly point to the re- 



ALVEOLAR ABSCESS. 305 

moval of the tooth. In the lower teeth, a very 
serious difficulty occasionally occurs from abscess, 
namely, an external opening and discharge ; and in all 
cases where this condition has already been reached, 
the offending tooth should be removed. But, when 
such a result is only anticipated, and is yet contin- 
gent, treatment may be employed to avert it; and, 
in order to do this, a deep and free incision should be 
made in the gum, opposite the affected tooth, and 
poultices applied within ; and, where there is ex- 
ternal swelling, pressure is recommended, as follows : 
adjust a piece of thick sheet-lead to the part, and 
make the pressure on this by means of a bandage 
comprising it and passing round the head. It is 
supposed that this application counteracts the gravi- 
tation of the secretion, pressing it upwards, and thus 
inducing it to seek an outlet at some more desirable 
point. If it is a worthless tooth that is producing a 
difficulty of this kind, it should be removed at once. 

In regard to the treatment of alveolar abscess, 
much yet remains to be learned. With the attain- 
ments thus far made in this direction, no aspiring 
dentist will rest satisfied ; though in the hands of a 
few it has made great progress within a very recent 
period. 

In a treatise of this character it is impracticable to 



306 ALVEOLAR ABSCESS. 

enter into the details of the pathology of this affection, 
or very minutely into the rationale of its treatment. 
A thorough knowledge of these involves a wide 
range of pathological knowledge. 



CHAPTER X. 

PIVOT TEETH. 

Whenever the crowns of the anterior teeth have 
become so much decayed that they can not by fill- 
ing, be rendered useful, they may, under favorable 
circumstances, be supplied by artificial crowns con- 
structed on the roots. For the successful accom- 
plishment of this work, the following conditions are 
important: 1. The constitution of the patient should 
be good. 2. The mouth should be in a healthy con- 
dition, and without diseased teeth or roots. 3. The 
teeth should be free from calcareous deposits and 
from all foreign substances liable to induce irritation 
or inflammation. 4. The attachment of the teeth 
should be perfect and healthy. 5. It is desirable 
that the root have a living, healthy pulp remaining. 
6. The root above the neck should be sound. 7. 
The root should occupy a correct position in the 
arch. Prior constitutional treatment will often be 
required where there are unfavorable conditions. 

The roots of the six superior anterior teeth are 
better adapted for the reception of artificial crowns, 



308 PIVOT TEETH. 

than those of any other in the mouth. The roots of 
the first bicuspids frequently terminate in two points, 
and are always more or less compressed, so that they 
will not receive a pivot large enough to sustain a 
crown; besides, these teeth are masticatory, and 
crowns pivoted to them very soon become loose and 
useless. The roots of the inferior incisors are also 
compressed, and thus subject to the same disability. 
Occasionally, however, pivot crowns are attached to 
the roots of the superior bicuspids, and the inferior 
incisors, cuspids, and bicuspids. But in order that 
such an operation shall be of any utility, the condi- 
tions must be favorable, the roots with as little lateral 
compression as possible, in a very sound and healthy 
state, and without any tendency to inflammation. 

The preparation of the root for the reception of an 
artificial crown, is a very simple process. It will, 
however, be somewhat modified by the kind of crown 
used, and the method of attaching it. Ordinarily, 
the first step is, to remove the natural crown, or any 
remaining portion of it, with a fine saw or excising 
forceps. Of this latter instrument, there are various 
forms, that in most common use having narrow, 
transverse edges, closing squarely together, as repre- 
sented in Fig. 57. With these forceps, any broken 
fragments of the crown can be removed with great 
facility. Many operators, placing their edge on the 



PIVOT TEETH. 309 

neck of the tooth, are accustomed to excise with 
them the principal part of the crown at a single cut. 
This method, however, is objectionable, since it 

Fig. 57. 




always gives too great a jar to the root, and is liable 
to loosen, and, in many instances, to fracture it so as 
to unfit it for the reception of the crown. But, in 
every case in which an artificial crown is required, 
the natural crown is very much decayed ; and, in this 
condition, is very readily removed with excising for- 
ceps, nipping it off in fragments, beginning where it 
is weakest and thinnest, and encroaching on it till it 
is all cut down — at least, as far as the forceps are 
available. Yet care is necessary even in this man- 
ner of using the forceps, lest the root be fractured or 
too much jarred. 

After such excision with the forceps, the root is to 
be dressed down for the reception of the crown, with 
a round, or, better, an elliptical file. But, for this 



310 PIVOT TEETH. 

operation of removing a crown, a very fine, smooth, 
narrow saw, set in a frame (Fig. 58), is, in some 
respects, preferable to the forceps, it being less liable 
to injure the root, than the latter. With this, the 

Fig. 58. 




crown is sawed off at the margin of the gum, leaving 
the end of the root about the form required for the 
reception of the artificial crown. In the process, the 
crown being sustained by the fingers, the saw, kept 
constantly wet, is applied to the tooth, and passed 
along its proximal side to the margin of the gum, 
and then along this through it, cutting it off at right 
angles with its axis. After the crown has been thus 
sawed off, the root is fitted, with a fine, round file, 
for the artificial crown; and, ordinarily, it should be 
dressed at right angles with its axis. 

At this stage of the work, if the pulp remains 
alive, it should be removed ; and the preferable 
method is by direct operation, in the manner already 
described (p. 263). It is better, in all such cases, to 
avoid the use of arsenic for destruction of the pulp. 
It will often be necessary to destroy the pulp before 
the crown is removed. For a successful operation, it 
is always preferable that the root have the pulp 



FITTING THE CROWN. 311 

living. After it is removed, the canal is to be 
enlarged to a suitable size, with the appropriate 
drill. If there is any remaining sensitiveness of the 
dentine, as is very seldom the case, the bur drill may 
be used for this purpose ; but if not, then the com- 
mon spear-pointed drill will be best. Where, how- 
ever, the canal takes the form of a mere fissure, 
either the bur drill or the four-sided broach may be 
employed. The depth to which the canal should be 
enlarged, will be determined by the length of the 
root ; but it should, in all cases, be sufficient, firmly 
to retain a pivot — which is from one to two lines ; 
and the diameter of the hole will be determined by the 
size of the root. The drills should be frequently 
moistened with water, to prevent their clogging. 
The shaft of the instrument, in the operation, should 
be in a line with the cutting edges of the two adjoin- 
ing teeth, and midway between them ; and the drill 
itself should follow the natural canal as nearly as 
possible. 

FITTING THE CROWN. 

The tooth selected should be of a size, shape, and 
color to correspond with the natural crown which it 
is to represent. It should not be ground on the 
sides or point 3 and according to general opinion, 
ought not to be touched with the emery-wheel at all. 



312 PIVOT TEETH. 

However a different opinion is entertained by Dr. C. 
Palmer, in which he suggests the grinding of the 
entire anterior surface of the artificial crown, thus 
removing the vitrified surface of the enamel; by 
which it is claimed that the appearance corresponds 
much better with that of the natural teeth ; which, 
in many cases, at least, is correct. The diameter of 
the neck of the crown should correspond with that of 
the articulating surface of the root to which it is to be 
attached. In fitting the crown to the root, the joint 
should be made as nearly perfect as possible ; for the 
tooth is thus more permanent and comfortable; an 
open joint offers a receptacle for the lodgment of 
food and other foreign substances, where they 
become vitiated, and produce unpleasant, if not inju- 
rious effects. The crown may be principally fitted to 
the root without a pivot, by dressing the latter with a 
round or elliptical file, and frequently trying the 
crown on in its proper position. After having been 
thus pretty accurately fitted, a trying pivot of soft 
wood should be introduced, by means of which, 
grinding it to its exact position, the crown may be 
fitted to the root in its proper position. 

For fitting pivot teeth, Dr. E. Townsend invented 
a round file, with a counterpart, into which the file 
exactly fits ; with the former of which the root is 
dressed, and with the latter, the articulating surface 



FITTING THE CROWN. 313 

of the crown. This apparatus would be good, were it 
not for the great difficulty of dressing porcelain teeth 
with a file. By care, a very complete fit can be 
made with a round file alone. Some coloring material, 
as rose pink, for instance, may be put on the base of 
the crown, and then the tooth, with the pivot inserted, 
set in its place — when the root will be marked where 
the crown has touched it, and this can be dressed at 
the point of contact. This operation is repeated till a 
perfect fit is attained. This method is to be recom- 
mended to those who have had but little experience 
in adjusting pivot teeth. 

Another method of making the articulation is, to 
dress the end of the root square, and then counter- 
sink it about half a line deep with a square-ended 
bur, about three fourths the diameter of the root. 
The base of the crown is then ground down, by the 
measure of the bur, perfectly round, so as exactly to 
fit into the depression in the root. The bur used for 
counter-sinking the root should have a center-point to 
fit into the hole in the root, and thus guide the instru- 
ment. This method of fitting on crowns is objection- 

Fio;. 59. 



able, by reason of its too great exposure of the root 
of the tooth. Fig. 59 represents the bur used for 



314 PIVOT TEETH. 

this purpose. It is a method now very seldom em- 
ployed. 

Still another method of making an articulation is. 
to dress up the root as first described ; then take an 
impression of the part in plaster of Paris ; and from 
this, get a model, to which to fit the crown. This 
method, however, is advisable only in cases where it 
is desirable to avoid annoyance to the patient by a 
tedious fitting process. 

ATTACHMENT OF THE CBOWN. 

The means of attachment in most common use is 
that of wood pivots; for which, wood in the natural 
condition is ordinarily employed, though it is much 
improved by compression. The kind best adapted 
for pivots is the fine-grain, tough, slow-growth hick- 
ory, of straight, uniform fiber, which should be 
thoroughly seasoned. For its preparation, take 
blocks, six or eight inches long, and split them into 
rods, about one fourth of an inch square ; then, with 
a knife and file, dress them down to a size one third 
greater than that of the intended pivots ; afterward, 
pass them through three or four holes of the ordinary 
drawplate inverted, thus making them of uniform 
thickness throughout : and finally, turning the draw- 
plate, pass them through it in the same manner as 



ATTACHMENT OF THE CROWN. 315 

wire, continuing till the rods are of proper size, and 
all the pores of the wood are closed by compression. 
They should be slightly oiled before being drawn 
through the plate. They may be drawn so as just 
to fit the holes of the artificial crowns, being, of 
course, of different sizes. Pivots thus compressed are 
stiffer, stronger, and far more durable ; and, there 
being greater density of fiber, there is less absorp- 
tion of moisture, less expansion, and less liability to 
decay, than in wood in the natural condition. 

In arranging the crown in position, care is necess- 
ary to prevent it from being struck by the teeth of 
the opposing jaw, — especially since it often happens, 
where the natural crown has been absent for some time, 
that the corresponding tooth of the lower jaw becomes 
somewhat elongated, and strikes forcibly against a 
properly adjusted pivot tooth. Such a difficulty is 
met either by filing off the elongated tooth, or by 
grinding out the palatal portion of the artificial 
crown sufficiently to accommodate the elongation. 
The former is the better method, and should always 
be adopted when inflammation of the dentine, exposure 
of the pulp, or an irascible condition of the surrounding 
parts, do not forbid it : though, in many instances 
both methods may be advantageously employed. 
But, by whatever means, the antagonizing tooth 
should always be prevented from coming in contact 



316 PIVOT TEETH. 

with the artificial crown ; and this latter should 
never press against the tooth, on either side of it; — 
indeed, it is better that there be a small interval on 
each side. 

When the crown is in its proper position, the hole 
in the root and that in the crown do not always have 
precisely the same direction ; in which case, a pivot 
will be required, having a curvature according to the 
variation ; and the extent and direction of such in- 
flection, should be carefully observed while adjusting 
the crown with the trying pivot. The pivot is to be 
neatly and accurately fitted into the crown first, and 
then the length of it required for the root, ascertained 
with the gauge represented in Fig. 60. This gauge 

Fig. 60. 



consists of a wire of a size freely to enter the pivot-hole, 
having a little slide with a flange attached. By in- 
troducing this wire into the pivot-hole, the slide is 
pressed back, and the depth of the hole indicated at 
once. The pivot is then cut off accordingly, and 
dressed to the proper size and inclination, and gently 
pressed to its place with the thumb and fingers. 
Before being introduced, however, it may be wrapped 
with gold foil, which will serve to protect the dentine 



ATTACHMENT OF THE CROWN. 317 

of the root from decay, and also to preserve the pivot. 
Two or three thicknesses of gold foil, too, may be 
placed between the crown and the root, so as to make 
a more perfect joint and exclude the moisture. There 
is, however, not much advantage in an arrangement 
of this kind ; a thin sheet of Hill's stopping placed 
in the joint, makes a better adaptation than the gold, 
and os artificial may be used for the same purpose, 
and in many instances is far better than either Hill's 
stopping or gold. The canal in the root above the 
pivot should be filled with gold ; though, in cases 
where there is a discharge through the root, this 
would not be admissible. 

The canal at the orifice is sometimes considerably 
enlarged by decay, so that when the crown is fitted, 
and the canal sufficiently opened for the reception of 
the pivot, there will be a cone-shaped space which 
the ordinary pivot will not fill. There are several 
methods of obviating this difficulty ; one of which is, 
completely to fill the enlargement with gold, and then 
perforate this filling with the proper-sized drill for the 
reception of the pivot; or, which is better, to intro- 
duce into the canal a polished steel wire of the size 
of the intended pivot; round this consolidate a 
filling of gold, having first made retaining points at 
the proper places in the dentine ; finish perfectly 
flush with the end of the root; and then withdraw 



318 PIVOT TEETH. 

the wire from the canal, and it is ready to receive the 
pivot with the crown attached. Some operators form 
the wood pivot of such a shape as to fit into and fill 
the enlarged cavity. Another method is, after the 
pivot is fastened into the crown, to build round it, on 
the base of this, a portion of Hill's stopping, of about 
the size and form of the enlargement in the canal; 
and then, the tooth being ready to insert, soften the 
stopping by heat, and introduce carefully into place. 
The os artificial in such cases is still better. 

It frequently happens, in c::ses where the pulp 
has been dead for a considerable time, that there is 
more or less discharge through the canal of the root, 
and a tooth is required immediately, or at least 
before there is time for treatment to abate the dis- 
charge. To such a condition some arrangement 
must be adapted, so as not entirely to close up the 
canal, and preclude the escape of pus. For this pur- 
pose, a groove may be cut down the wall of the canal, 
or, perhaps better, on the side of the pivot through- 
out its length, for the discharge of the secretion. 
Where there is irritation or liability to inflammation, 
a temporary pivot of soft wood, or of hard wood 
loosely fitted, should be worn ; for thus the root is 
less jarred by percussion on the crown, and, if need 
be, the crown and pivot can be removed. 



METALLIC PIVOTS. 319 



METALLIC PIVOTS. 



The liability of a pivot of wood to wear off at the 
point between the crown and the root, as well as to 
become offensive, and the difficulty of removing the 
tooth, have led dentists to seek some less objection- 
able material; and metals have been experimented 
upon, and found in some respects preferable. Gold 
has been employed for this purpose more than any 
other metal. Pivots made of this do not become 
offensive, do not wear off; and admit of any desired 
curve, and of an easy removal of the crown. There 
are several methods of attaching this kind of pivot 
to a tooth; and a very common one is, to fit into the 
hole in the crown a piece of pivot wood— cut it off 
even with the base of the crown, and perforate it 
with the proper-sized drill for the reception of the 
metal pivot, which may be roughened, or barbed on 
its sides, and then forced into the place prepared for 
it. Another method is, to drill into a block of wood ; 
insert the pivot, prepared as above, then dress down 
the wood round it till this will fit closely into the 
crown; and, after it is pressed in, cut off the pro- 
truding portion of wood. In either of these methods, 
when the wood becomes moist, the metal pivot will 
be very firmly retained. This pivot may also be at- 
tached to the crown by soldering : place the edge of 



320 PIVOT TEETH. 

the tooth in plaster of Paris; set the pivot in its 
proper position in it ; fill round this with fragments 
of gold plate, and put on solder and borax ; heat up 
with a blow-pipe, and draw the solder to the bottom 
of the cavity. Another method, sufficient for all 
practical purposes, is 5 to set the pivot in place, and 
pack round it a stiff amalgam of gold and mercury, 
evaporate the mercury by heat. A better method 
than any of these is, to have teeth manufactured with 
a platinum tube inserted, into which the pivot can be 
soldered. Pivots may also be attached to the ordi- 
nary plate teeth. 

For attaching the metal pivot to the root, it is 
sometimes fitted tightly to the canal, and introduced 
into it without any other substance. This is object- 
ionable, on account of the wearing of the root, certain 
to take place, if there is the least jarring or moving 
of the crown. To obviate this, various methods 
have been devised; one of which is, to wind floss 
silk about the pivot before introducing it; but this 
soon becomes offensive, and requires frequent re- 
newal. Another method is, to introduce a piece of 
wood into the root, and drill through it for the re- 
ception of the pivot, which is squared and roughened 
— squared to prevent it from turning round, and 
roughened to secure it from drawing out. But if it 
is desirable to remove the tooth occasionally, the 
pivot should not be barbed. 



METALLIC PIVOTS. 321 

Metal tubes may be introduced into the roots for 
the reception of the pivots. These tubes are made of 
hollow gold wire of proper size ; the method of pre- 
paring which, is, to take a piece of No.-30 gold plate, 
from four to six inches long, and from a third to a 
half an inch wide, and bend it round a piece of smooth 
polished steel wire of the size of the intended pivot; 
draw both together through a drawplate, down to one 
size larger than the hole in the root ; then take out the 
wire, and solder up the tube ; on it cut a fine thread 
with a screwplate ; from it cut off from a half to three 
fourths of an inch in length, and insert into this a 
piece of the wire it was drawn upon ; grasping this 
section with a small vice or pair of nippers, screw it 
carefully into the root; and having introduced it 
far enough, withdraw the piece of wire, cut off the 
protruding piece of tube with a fine saw, and file and 
neatly polish. The root is thus ready for the recep- 
tion of the crown, the pivot of which should fit very 
accurately into the tube. A very slight curvature of 
the pivot will enable it to retain a very firm hold in 
the tube. The tube's inner end may be soldered up 
if desirable ; and, if there is decay at the orifice of 
the canal, a flange may be soldered on to its outer end, 
flush with the end of the root, and the decayed 
cavity filled beneath it, the flange serving to retain 
the filling perfectly in place. These tubes can be 

v 



322 PIVOT TEETH. 

best fitted in with the screw, though they are some- 
times placed in without this, aud gold foil packed about 
them to retain them. They may be made to receive 
a square pivot, by being drawn, in their manufacture, 
on a square wire, instead of a round one. For the 
escape of pus, as already referred to, the pivot may 
be made of hollow wire, with a hole through the 
crown of the tooth. 

A plate tooth, with a metallic pivot attached, may 
be used instead of the ordinary pivot tooth ; and it 
is in some cases required, on account of the manner 
in which the teeth antagonize. But in all cases 
where a plate tooth is used, it should have a metallic 
base to rest on, and cover the end of the root. Pro- 
perly to construct this, an impression must be ob- 
tained, and models and countermodels made, and 
the base swaged ; and then to this the pivot and 
tooth are attached. Irregularity of the teeth, and 
especially of the root on which the crown is to rest, 
may require a peculiar adjustment of the pivot, which 
may be very happily effected by the method just re- 
ferred to. 

Occasionally, bad consequences follow the opera- 
tion of inserting a pivot tooth, the most frequent of 
which is, inflammation of the periosteum. Rough 
manipulation is very liable to induce this condition, 
where there is an inflammatory diathesis ; in which 



METALLIC PIVOTS. 323 

case, too great care can not be recommended ; and 
prior treatment will sometimes be advantageous. 
After periostitis has supervened, either constitutional 
or local treatment, or both, may be employed ; con- 
stitutional, by emetics and saline cathartics, and, 
indeed, any agent that will equalize the circulation 
and counteract the inflammation ; and local, by the 
same means as already prescribed for periostitis else- 
where — in addition to which, it may sometimes be 
necessary to remove the crown and pivot from the 
root. It is always important to commence the treat- 
ment of such cases at the first indications of the 
disease. 

Sometimes, even with considerable care, a crown 
will be split by the introduction or the expansion of 
the pivot ; in which case, of course, another tooth 
must be selected. When a pivot breaks off, and a 
portion adheres in the root, this may be drawn out 
with pliers or a pivot-extractor, or, if it does not pro- 
trude enough for this, it may be drilled out. A root 
is sometimes split by the expansion of a tightly-fitting 
pivot, or by a blow on the crown of the tooth ; and 
when this happens, it must be removed, since it can 
not be made any longer to retain a tooth. Pivot 
teeth should seldom, if ever, be worn in a mouth in 
which teeth on plate are worn. They are now far 
less frequently worn than formerly, because, perhaps, 



324 PIVOT TEETH. 

of the improved methods of inserting teeth on plate. 
Under favorable circumstances, however, they may 
be worn with great comfort and usefulness, from five 
to fifteen years. 



CHAPTER XI. 

EXTRACTION OF TEETH, 
GENERAL REMARKS. 

The extraction of teeth is an important operation, 
requiring, for its proper performance, skill, judgment, 
and experience, as well as an accurate knowledge of 
the parts involved. Success in the operation formerly 
was very uncertain; but now, from an increase of 
knowledge in the art of dental surgery, and from 
great improvements in the instruments employed, the 
operation is generally attended with success. The 
ancients were not strangers to this operation, as is 
evidenced by relics found in ancient tombs, with 
teeth absent, under such circumstances as to warrant 
the conclusion that they were removed by the sur- 
geon. Extracting instruments of very ancient date 
have also been found ; and ancient writers, too, refer 
to the operation as one not much more pleasant then 
than now. The demand for this operation rises not 
from fancy, fashion, or caprice, but from dire necess- 
ity — a necessit}^, too, of great frequency. Very few 
individuals in this country arrive at mature ago with- 



326 EXTRACTION OF TEETH. 

out being required to submit to it ; and, indeed, the 
majority, before middle age, lose in this manner from 
four to ten teeth, and many, all. The following are 
some of the objects for which a resort is had to this 
operation : — 

1. To obtain relief from pain, caused either by 
disease of the pulp, by inflammation of the perios- 
teum, or by any other affection involving the teeth, 
that can not be readily controlled without their 
removal. 

2. To prevent pain in future. This, of course, has 
reference only to those teeth which are very much 
decayed, or rendered useless by any cause, and which 
are liable at any time to occasion disease in the parts 
about them. 

3. To save sound teeth from the attack and ravage 
of decay. This implies those teeth which, by their 
offensive condition, would prove injurious to healthy 
teeth. 

4. To relieve a diseased condition of the contigu- 
ous parts, such as alveolar abscess, neuralgia excited 
by dental irritation, diseased antrum — and sometimes, 
indeed, remote parts, which are in many instances 
affected by diseased teeth. 

5. To anticipate and obviate irregularity. Of this 
there are many cases, in which all the teeth can not 
be accommodated with a proper position in the arch, 



GENERAL REMARKS. 327 

and in which the removal of one or more of them, for 
this purpose, becomes a necessity if regularity and 
symmetry are to be secured. 

6. To prepare the mouth for a proper reception of 
artificial teeth on plates. Though plates are some- 
times inserted, with the roots of teeth remaining, 
which is admissible only when the roots and the parts 
about them are healthy; otherwise they should be 
removed. 

Before anything else is done, every case presented 
should be carefully examined, in order to ascertain 
all the circumstances and conditions that might in 
any way affect the operation. It is important to 
arrive at a correct conclusion in regard to the tooth 
or teeth to be removed ; the number of roots, their 
inclination, and the character of their attachment; 
in what manner, and to what extent the surround- 
ing parts will be affected by their removal ; and the 
probable amount of force necessary for this purpose. 
The operator will, in many instances, be referred to 
the wrong tooth ; for a sound and healthy one is 
sometimes painful from sympathy, and, standing in 
contact with a decayed and painful tooth, makes it 
many times difficult for the patient to determine in 
which the pain exists ; and sometimes difficult for the 
operator, too, especially where the decay is on a 
proximal portion of the tooth, and not easy of 



328 " EXTRACTION OF TEETH. 

approach. In all such cases, great care should be 
exercised, and a thorough examination made. There 
is often extensive decay on the proximal portion of 
the tooth, that is not apparent at first view. 

The constitution is also to be noted — its peculiar- 
ities, tendencies, and susceptibilities ; as these will 
often modify the operation. A highly nervous tem- 
perament will not endure an operation that one of 
a different character will undergo with impunity. 
There may also be idiosyncrasies and conditions that 
will forbid the extraction of a tooth. One of these, 
and not the least formidable, is a hemorrhagic dia- 
thesis. 

The manner of performing the operation is an im- 
portant consideration : it should not be precipitate 
or hurried. A very good criterion is, that the eye 
should critically follow, and the mind attentively 
comprehend every movement of the hand and instru- 
ment. It is a very common method, to seize the 
tooth, turn away or shut the eyes, and make the 
most rapid motions possible, regardless of conse- 
quences. Accidents, such as breaking the tooth, 
fracturing the alveolus, laceration of the soft parts, 
and rupture of the blood-vessels, are very liable to 
follow a hurried execution; and there are many 
cases on record, in which injury has resulted from a 
rapid application of force in the extraction of teeth. 



GENERAL REMARKS. 329 

The ancients were cautious in this particular : it is 
recorded of them, that they made extracting instru- 
ments of lead, to prevent injury from the employ- 
ment of too great force. It is difficult, indeed, 
always to determine what amount of force may be 
necessary for the removal of a tooth in any given 
case ; though by long and close observation, it may 
be pretty accurately calculated ; and it is important 
for the operator to know it, so as to prepare for the 
emergency, and to select the instrument appropriate 
to the occasion. In order to be successful, an ope- 
rator must be confident of his ability, and, to be so, 
must be possessed of it. He should be familiar with 
the anatomical structure of the parts to be operated 
upon; should understand the physiological and the 
pathological conditions of the parts adjacent; and 
should properly appreciate their influence on, and 
their connection with, the teeth. 

There is a great difference in teeth with regard to 
their facility of removal. Those most difficult to ex- 
tract, possess the following peculiarities : shortness 
and thickness of crown ; in the incisors, thickness — 
the edges of the superior and the inferior meeting 
squarely on, or deviating but little from their points ; 
freedom from prominences on the crowns of the mo- 
lars and bicuspids, their masticating surfaces being 
smooth; regularity in arrangement, all being in cor- 



330 EXTRACTION OF TEETH. 

rect position and in contact with one another ; color 
slightly yellow ; denseness and thickness of alveolus ; 
unyielding firmness of the soft tissues ; lack of promi- 
nences on the gums to indicate the size and position 
of the roots. Another class of teeth, differing in 
characteristics from those of the above, are also very 
difficult of extraction, namely : those having crowns 
of medium length and of a diameter at the neck much 
less than at the masticating surface ; roots long and 
divergent, and in some cases considerably curved ; 
and often a very firm union with the alveolus, so that 
a portion remains adhering to the tooth when it is 
extracted; which occurs more frequently with the 
superior cuspid teeth than with any others ; and often 
the septum between the roots is so firmly embraced 
by them, especially when they converge, that it is 
brought away with the tooth on its extraction. Bony 
uniou of the teeth has been enumerated as one of the 
occasional obstacles in extraction of the teeth ; but 
this rarely if ever occurs — the mode of development 
almost precluding the possibility of its existence — so 
that it need scarcely be reckoned. Exostosis of the 
root sometimes renders extraction very difficult, 
especially when the enlargement attaches to the point 
of the root, and forms a bulb larger than the diame- 
ter of the root elsewhere. It is then like a ball in a 
socket, and, if the walls of the alveolus are thick and 



GENERAL REMARKS. 331 

firm and closely embrace the root, the tooth is very 
securely retained. Exostosis of the same extent in 
the inferior as in the superior teeth, will reader the 
latter the more difficult to remove, because of the 
greater density of the inferior maxilla; and it has 
been maintained that this cause would produce a 
like difference even in the normal condition of the 
organs ; but experience does not warrant the opinion. 
The superior molars have more numerous and more 
divergent roots than the inferior ; and the roots of the 
anterior superior teeth are much larger, and conse- 
quently have a greater amount of attachment, than 
the anterior inferior ones. In a healthy condition, 
the periosteum of the root has comparatively little 
sensibility ; but in proportion as it is subjected to 
acute disease, is the sensibility, and thus the pain 
consequent on the removal of the tooth, augmented. 

Instruments adapted to all the different forms and 
locations of the teeth, are requisite in the various 
operations of extraction. It is impossible to remove 
all teeth in a proper manner with but three or four 
instruments, as recommended by some. 

For any kind of successful manipulation in the 
mouth, and especially that involved in the extraction 
of teeth, the patient should be placed in such a posi- 
tion as to make him the most comfortable, and to 
secure to the operator the greatest facility of execu- 



332 EXTRACTION OF TEETH. 

tion. But different positions, of course, will be re- 
quired for the removal of different teeth. Finally, 
there should be as little show of preparation, and as 
little display of instruments as possible — thus to 
avoid exciting the nervous apprehensions of the 
patient ; and the operator should at all times exhibit 
a gentle and encouraging deportment, yet work 
promptly and surely. 

INDICATIONS FOR EXTRACTION. 

The most common and imperative indication is, 
continued and violent toothache. In all cases where 
the teeth are diseased and painful, and can not be re- 
stored to health, the}^ should be removed. There 
are, however, few cases of diseased teeth, that cannot 
be relieved by the present methods of treatment, so 
as to remain in the mouth with some degree of com- 
fort and usefulness. Alveolar abscess terminating on 
the outside of the face, or tending to it, always indi- 
cates the removal of the offending tooth. Chronic 
inflammation of the investing membrane used to be 
considered an indication for extraction; but it is 
found that many cases thus affected, may, by judi- 
cious treatment, be restored to comparative health. 
Ulceration of the investing membrane clearly points 
to extraction as the remedy. Teeth that have no 



INDICATIONS FOR EXTRACTION. 666 

antagonists, and that, on this account, keep up an ir- 
ritable condition in the contiguous parts, should be 
removed ; and so, as a general rule, should super- 
numerary teeth. In order to relieve a crowded con- 
dition of the teeth, it is sometimes necessary to remove 
one or more, even though they may be healthy. 

Till within the last few years, the existence of an 
alveolar abscess was considered an indication for the 
removal of the tooth from which it proceeded ; but, 
under the present mode of treatment, except in very 
aggravated cases, a simple abscess is not reckoned a 
sufficient cause for extraction. 

The posterior teeth may be removed for causes 
that would not warrant the removal of the anterior. 
All dead teeth and roots that produce or keep up irri- 
tation, should be removed, especially if the tendency 
is persistent. 

The temporary teeth that are not cast at or hear 
the time their respective permanent teeth should ap- 
pear through the gum, ought to be removed; but 
caution must always be exercised, lest they be re- 
moved too soon. Painful and uncontrollable disease 
may indicate their removal long before the period just 
mentioned; yet they should not be removed on ac- 
count of diseased condition, unless the rudiments of 
the permanent teeth are likely to suffer thereby. A 
crowded condition of the permanent with the tempo- 



334 EXTRACTION OF TEETH. 

rary teeth, may indicate the removal of one or more 
of the latter. It is important to understand the true 
indications for the removal of temporary teeth ; in 
these, as in the permanent teeth, apparent indications 
are liable to be mistaken for real ones. Teeth may 
sometimes, even though undecayed, produce nervous 
affections, and in such a manner as to render their 
removal necessary. This indication is most frequent 
with teeth affected by exostosis. 

A high state of inflammation in the contiguous 
parts, is regarded by some as a counter indication ; 
but it can be such only in cases in which the inflam- 
mation would be increased by the operation ; and this 
would happen only where there is a decided inflam- 
matory diathesis; which peculiarity can be readily 
detected by careful observation. 

EXTRACTING INSTRUMENTS. 

Numerous and various instruments have been em- 
ployed for extracting teeth ; and each of these has 
passed through various modifications. Imperfection 
and inadaptation have, till within a few years, char- 
acterized them all in a marked degree, as indicated 
by the numerous changes they have undergone. Two 
general classes comprehend them all — represented by 
the key and the forceps. The former makes its 



EXTRACTING INSTRUMENTS. 335 

attachment on one side of the tooth, coming in con- 
tact with but a small portion of it, and has a resting 
point for a fulcrum on the adjacent parts, the gum 
and the alveolus. The latter embraces the tooth on 
both sides, and has no fulcrum resting on the adjacent 
parts. There are other instruments somewhat differ- 
ent from these in their application ; but the principle 
on which they operate, is the same. For instance, 
the elevator has a point of embrace or contact with 
the teeth, and a fulcrum or resting point on the ad- 
jacent parts, the power being applied to the handle, 
as to a lever. The screw makes its attachment inside 
of the tooth, instead of outside, like the forceps, and 
does not touch any other part. 

There should always be at hand a sufficient 
number and variety of instruments to meet every 
case, however rare its occurrence. Desirabode re- 
commends the employment of but four instruments 
for the removal of all the teeth : the first is a forceps, 
and the other three are nothing more than so many 
different forms of the elevator. He was not familiar 
with the present improvements in extracting instru- 
ments, or he could not have made such a recommen- 
dation. 



336 EXTRACTION OF TEETH. 



THE KEY. 

The principle of this instrument was, at a very 
early period, brought into requisition for the extrac- 
tion of teeth ; it is, emphatically, an old instrument. 
It consists of a shaft six inches long, with a handle 
four inches, attached at right angles, while the hook 
is attached laterally at the other end of the shaft, 
and the bolster, either movable or fixed, to the side 
of it, immediately below the articulation of the hook. 
This instrument has passed through a great variety of 
forms and modifications ; having the shaft straight, 
curved, or double-curved ; the fulcrum large, small, 
flat, round, long, short, fixed, movable, and anterior, 
posterior, or opposite to the point of the hook. There 
has also been a great variety of forms of the hook ; 
and it has been made with machinery attached, to 
control its grasp, the object of which is, to prevent 
the instrument from slipping off the tooth, and skill 
in the use of which would doubtless add to the effi- 
ciency of the instrument. The principle of the forceps, 
too, has been combined with the key, and probably 
with very decided advantage. 

The modus operandi of the key is worthy of some 
consideration. The hook is attached to the shaft 
directly above the bolster, and starts off at right 



THE KEY. 337 

angles with its vertical axis, but curves down to the 
point, almost or quite as low as the base of the bolster. 
When properly constructed, the hook embraces the 
tooth at the neck on one side, and the bolster rests a 
little below this on the other. When the instrument 
is applied to a tooth, the center of the shaft is the 
axis of motion ; but, as force is applied to the instru- 
ment, this axis is transferred from the shaft to the 
base of the bolster, which is the center of motion the 
moment it is fixed on the gum and alveolus, and the 
shaft describes an arc about it. Now, as a result of 
this motion and arrangement, the line of force is at 
an angle of from forty to sixty degrees with the axis 
of the tooth ; and hence it is at this angle that the 
tooth must be extracted, if at all. The axis of power 
exerted on the tooth by the instrument, is in a line 
from the point of the hook to its attachment to the 
shaft; and the line of this force has its termination 
below the neck of the tooth on one side, and just 
above the crown on the opposite side. The angle 
formed by the line of power with the axis of the 
tooth, is different in the different relative positions of 
the key to the tooth. If the instrument is applied to 
an inferior molar, with the bolster on the inside, the 
angle of the line of force with the axis of the tooth is 
about forty degrees; but, if placed on the outside of 
the jaw, as recommended by some, the angle con- 



338 EXTRACTION OF TEETH. 

rained by the line of power and the axis of the tooth, 
is sixty degrees or more. The line of force is not 
changed by any form the hook may assume ; — it may 
be regularly cr irregularly curved, or be turned at 
right angles, and yet the line of force is not changed. 
Indeed, this line can not be changed, except by 
changing the relative position of the hook and its at- 
tachment. This application of the power constitutes 
one of the prominent objections to the use of the in- 
strument : the force is applied at too great an angle 
with the axis of the tooth, and her.ce, in numerous 
instances, it is broken off. The bolster of the key 
rests, in the operation, on the gum, on which it 
exerts great pressure, and which it always bruises, 
and frequently lacerates in a cruel manner ; the press- 
ure exerted by the bolsters of the variously con- 
structed keys differs but little ; though, perhaps, the 
bolster which has a broad base, and attached to 
the shaft by a joint, would cause less pain to the 
patient by its pressure, and be much less liable to 
lacerate or cut the gum, than the small and perma- 
nent one. The pressure of the bolster on the gum 
and process is always greater than the power required 
to extract a tooth ; and this extreme pressure and its 
consequences constitute another strong objection to 
the use of the key. The power being applied at a 
disadvantage, much more is required than when 
economically applied. 



THE KEY. 339 

This instrument is so seldom employed for the 
extraction of teeth, that any very special directions 
as to its use will scarcely be required ; yet a few gen- 
eral suggestions may not be out of place. Whether 
a tooth should be drawn inward or outward depends 
on its position and inclination. As a general rule for 
the removal of the molars, the bolster should be 
placed on the inside of the inferior teeth, and on the 
outside of the superior. For removing the lower teeth 
of the left side, the operator should stand at the right 
of the patient ; and for the teeth of the right side, in 
front or at the right. For the inferior teeth of the 
right side, he should stand at the right of the patient ; 
and for the left superior, in front of him. There have 
been a great many different opinions as to the manner 
of applying and using the instrument. One recom- 
mends that " the teeth should be always turned 
towards the tongue." Another, "that the fulcrum 
should be so placed that it w T ould not come in contact 
with the tooth." Another directs : " Place the ful- 
crum on the margin of the gum." Another : " Place 
the fulcrum on the gum below its margin." Another 
suggests, " that the fulcrum be placed on the side of 
the tooth opposite the point of the hook." Again. 
we are directed "that the tooth should be drawn 
from the higher alveolus." This great diversity of 
opinion as to the manner of using the key, as well as 



340 EXTRACTION OF TEETH. 

the great variety of changes in its form, is evidence 
that it is, at best, a very imperfect instrument. It is 
impossible to embrace a tooth as deep with it as with 
well constructed forceps ; and with it, the liability to 
accident in the extraction of teeth, is much greater 
than with any other instrument. A strong advocate 
of this instrument says that " the key always produces 
injury; but the greatest skill exhibits the least 
injury." 

FORCEPS. 

The forceps are the most efficient extracting instru- 
ments in use ; and the improvements made in them 
during the last few years have been very great; 
indeed, twenty years ago, they were not made with 
any special adaptation whatever, and were totally 
unfit to be used for the extraction of teeth ; but now, 
they are constructed with such various shapes and 
curves as to facilitate their approach to the teeth, 
whatever thefr position in the mouth may be, and to 
fit all the various forms, and make the most perfect 
embrace of the teeth possible. Forceps, with the pre- 
sent improvements, take a deeper and more thorough 
hold on the teeth than any other instrument. The 
beaks may be made so thin that they will penetrate 
between the roots and alveolus, and the adaptation so 



FORCEPS. 341 

complete that the instrument will not slip or move from 
its position when placed. The form of the beaks 
should be such as to fit the crown without pressing on 
it, and yet perfectly embrace the neck of the tooth ; 
and the entire instrument of such form and curve as 
to give to the hand, arm, and body of the operator the 
best position for ease and facility of execution. 

There are various opinions as to the position rela- 
tive to the patient which the operator should occupy 
while extracting teeth with the forceps. Some re- 
commend different positions for the removal of differ- 
ent teeth ; but it is preferable, on many accounts, to 
occupy as nearly as possible the same position in the 
removal of all ; and this is at the right and a little 
back of the patient. 

The forceps for removing the superior incisors are 
straight, and have thin beaks, which are sufficiently 
broad to embrace the anterior and the posterior sur- 
faces of the teeth entire (Fig. 61) ; and they should 

Fig. 61. 




be much broader for the centrals than for the laterals. 
The points should not be so broad, however, as to 



342 EXTRACTION OF TEETH. 

corne in contact with the contiguous teeth, in the 
rotary motion made to break up the attachment. 
The same principle in regard to the width of the for- 
ceps is to be observed for the lateral incisors and 
cuspids. The ordinary straight, root forceps, may be 
employed for the extraction of the lateral incisors ; 
though, for this purpose, it is desirable that their 
beaks be somewhat thinner than usual. For the 
superior cuspid teeth, the ordinary bicuspid forceps 
are frequently used ; but their beaks are commonly 
too narrow, and those of the central incisor forceps 
too thin. The cuspid forceps should be about as 
wide as those for the central incisors, with the thick- 
ness of the bicuspid forceps (Fig. 62), and with a 

Fig. 62. 




greater concavity, so as to fit the neck of the tooth. 
The superior bicuspid forceps have narrow, thick, and 
quite concave beaks, and the instrument is straight, 
or nearly so ; though for the second bicuspids, 
especially in a small mouth, it should have some 
anterior curvature. (Fig. 63.) One pair of forceps 
will serve for both sides, though it is desirable to 



FORCEPS. 343 

have one for the first, and another for the second 
bicuspid. For the removal of the bicuspids, there is 

Fie. 63. 



a form of forceps with thick, smooth beaks, and of 
such a form as, by pressure, to force the tooth from 
its socket, taking advantage, for this purpose, of the 
conical form of the root. The superior molar for- 
ceps, a pair for each side, have one of the beaks a 
single concave, to embrace the palatine root, and the 
other a double concave, with a projecting point from 
the center of the beak, to pass into the bifurcation, 
and with the edge of the beak so formed as to em- 
brace the two palatine roots. The concavity and 
curvature of the beaks should be first just sufficient 
to accommodate the crown of the tooth. These for- 
ceps should have a double curve, to facilitate their 
approach to the teeth — an anterior curve just above 
the joint, and a downward curve just below it ; 
sometimes, also, a lateral curve above the joint, 
throwing the instrument more toward the angle of 
the mouth. (Fig. 64.) 

For the second molars, the forceps should have a 
little more curve above the joint, than for the first. 



344 



EXTRACTION OF TEETH. 



A third pair of forceps for these teeth, and especially 
for the roots before they are separated, have the inner 

Fig. 64. 




beak similar to the one above, and the outer a 
curved, attenuated, sharp point, to pass between the 

Fig. 65. 




buccal roots (Fig. 65.) The forceps for the superior 
dens sapientice have two single-concave beaks, made 



FORCEPS. 



345 



to embrace the tooth, as though it were cylindrical, 
or nearly so, at its neck. The instrument has two 
curves, or rather angles, the one forward, and the 
other downward, so that its handle is somewhat an- 
terior to, but almost parallel with, the axis of the 
tooth. (Fig. 66.) It is a principle that should be 

Fig. G6. 




observed in all forceps, that the handle of the instru- 
ment when placed upon the tooth be as nearly par- 
allel with the axis of the latter as possible, and as 



Fig. 67. 




nearly in a line with it as the location of the tooth, 
the size of the mouth, and other circumstances will 
admit. 

The forceps for the inferior incisors may have 



346 



EXTRACTION OF TEETH. 



either a lateral or a transverse curve — almost to a 
right angle, if transverse, but if lateral, not more 
than half that inclination. (Fig. 67.) The ordi- 
nary, slightly curved root forceps may be used for 
the extraction of these teeth. (Fig. 68.) The 

Fig. G8. 




beaks should be very narrow and thin ; for a great 
amount of force is not required for the extraction of 
these teeth. The beaks of the inferior incisor for- 

Fig. 69. 




ceps should be relatively broader than those of the 
forceps for the superior incisors. Rotary motion in 
the extraction of inferior incisors, is not admissible 
unless the roots be cylindrical or nearly so. The in- 



FORCEPS. 



347 



ferior bicuspid forceps are well adapted to the removal 
of the inferior cuspids also. These forceps, two in 
number, one for each side, are of different forms. 
(Fig. 69.) The beaks are narrow, thick, and quite 
concave. The instrument for the right side has a 
lateral curvature, which brings the handle out at the 
angle of the mouth, and is necessary in order to ob- 
viate a contact with the superior teeth. The forceps 
for the left side have beaks of the same form. They 
are bent to almost a right angle above the joint, 
while below it the handle is thrown upward ; and 

Fig. 70. 




their inner beak is longer than the outer. The inferior 
molar forceps (Fig. 70) are two in number, that for the 
right side being curved outward and forward, and 
that for the left forward and upward, the beak making 
almost a right angle w r ith the body of the instru- 



348 EXTRACTION OF TEETH. 

merit, and the inner beak of each being longer than 
the outer. The beak should be of sufficient breadth 
to embrace the entire side of the tooth, of double- 
concave form, with a ridge and a long point in the 
center of the beak, to pass into the bifurcation of the 
roots. The inner beak of these forceps should be 
longer than the outer 5 for the teeth on which they are 
designed to operate, have an inward inclination, and 
the outer alveolus is higher than the inner. 

A pair of forceps for the left side, similar in form 
to those for the right, would be preferable to the 
ordinary left forceps, when the mouth can be opened 
wide ; and the curvature of the handle of this instru- 

Fie. 71. 




ment would be toward the center of the mouth, in- 
stead of outward, as that of the right forceps. With 
this form of forceps, more power can be exerted than 
with the ordinary left inferior forceps. 

Forceps for the removal of the inferior dens sapi- 
entice have large single-concave beaks, to make a 
general embrace of the tooth, and have but one 
curve, which is between the joint and the point, and is 
almost a right angle. (Fig. 71.) One pair of forceps of 
this kind is quite sufficient for both the right and the 



FORCEPS. 349 

left side. The forceps denominated Physics forceps, 
are also sometimes employed for the removal of the 
wisdom-teeth. These are constructed with thick, 
sharp blades, the edges of which come squarely 
together, and the points sometimes have an enlarge- 
ment on them. They are curved almost to a right 
angle, to facilitate their adaptation. (Fig. 72.) 
There are two or three different forms of Physic's 
forceps. 

Fig. 72. 




Of the variety of root forceps now used, those for 
the removal of the anterior teeth, are straight, or but 
slightly curved, with long, thin, sharp-edged beaks, 
and of a width regulated by the diameter of the roots. 
Those for the removal of the roots of the superior 
molars, when these are separated, have the same form 
of beaks as those for the front teeth, but more curved, 
to facilitate their approach to the roots. For the re- 
moval of these roots, it is well to have several pairs 
of forceps with different degrees of curvature, using, 
in any given case, those with the least admissible 
curve — which, in a small mouth, will be considerable, 
while in a large one, it will be very slight. The same 



350 



EXTRACTION OF TEETH. 



forceps that are used for the removal of the front 
inferior teeth, are applicable to the removal of their 
roots. 

Of the different forms of forceps for the removal of 
the roots of inferior molars, those for the extraction 
of the roots before they are separated, and while they 
are firmly attached,, have two long, slender, round, 
curved beaks, designed to pass down deep between 
and embrace the roots in the bifurcation ; their curva- 
ture should be almost a right angle, and their handles 

Fig. 73. 




assume the form of the ordinary right and left inferior 
molar forceps, already described (Fig. 73) ; or, if but 
one is used, the handle should be straight. The for- 
ceps for the removal of these roots after they are 
separated, should have the beaks of the same form as 
those of the superior root forceps ; but the beaks 



ELEVATORS. 



351 



should be curved to a right angle with the handle, and 
the handle be straight. (Fig. 74.) 

Fig;. 74. 




ELEVATORS. 

There are in use variously formed instruments 
constructed on the principle of the elevator. They 
are made with such points as to take the most tho- 
rough hold on the teeth or roots on which they are 
to be used, and with such curvature of shaft as to 
enable them to pass most readily to the desired posi- 
ng. 75. 




tion. Some Jare so formed at the points as to em- 
brace the root at the border of the alveolus, using 




the latter as a fulcrum (Fig. 75) ; others, to pass 
between the alveolus and the root (Fig. 7C) ; others, 
to cut through the alveolus, and thus approach the 



352 



EXTRACTION OF TEETH. 



root. All the ordinary elevators make a fulcrum of 
the alveolus or of an adjoining tooth; but some ope- 
rators, in using this instrument, contrive to make a 
fulcrum of the thumb or one of the fingers ; which is 
the preferable way. 



HOOKS. 

These are formed so that the point shall embrace 
the root and remove it, without resting on the sur- 
rounding parts. The root is removed simply by 

Fig. 77. 




pressure, applied in the proper direction. Of the 
various forms of this instrument, there are the for- 
ward hook, the backward (Fig. 77), and the com- 
pound (Fig. 78), which last includes the former two. 




These are valuable instruments, but require care in 
order to avoid injuring the surrounding parts. 



SCREW. 



353 



SCREW. 

This is a cone-shaped instrument, with a very 
definite, sharp screw-thread; the manner of using 
it in the operation of extraction is, to screw it into 
the root. It will be required of various sizes to 
correspond with those of the different roots to be 
extracted. It is commonly attached to the handle 
by a permanent shaft (Fig. 79) ; but, sometimes, it is 

Fig. 79. 




made with a square shaft fitted into a socket handle 
(Fig. 80), by which arrangement the handle is used 
only to introduce the screw ; and this serves only as 
a support to a frail root, the forceps being then brought 

Fig. 80. 




e{&&* 



to bear in connection with it, for the removal of the 
root. A screw-tap, of the same form as the screw, 
should accompany it. 

When the screw is combined with the forceps, for 
the purpose of supporting the root and preventing 
it from crushing while it is removed with the forceps. 



354 EXTRACTION OF TEETH. 

the latter is of the same form as that of the ordinary 
straight root forceps, with the shaft of the screw at- 
tached in the joint. In some, the screw is attached 
with a spring and ratchet, so that it can be drawn 
out, seized between the beaks, and introduced into 

Fig. 81. 




the root; and then these are slipped on the root, 
which they embrace and remove. In others, the 
screw is fixed ; but the movable screw is to be pre- 
ferred. (Fig. 81.) An arm attached by a joint, and 
bearing a pad, to rest as a fulcrum on the other teeth, 
is sometimes attached to the shaft of the screw ; but 
this is objectionable because of its liability to impede 
the action of the instrument, and also to injure the 
adjoining teeth. 

GUM-LANCET. 

Of the various forms of the gum-lancet, the most 
common is that with the round point, and with the 
blade from two to four lines wide, and from half an 
inch to an inch long, attached to a shaft and handle ; 
the whole being about six inches in length. The in- 
strument should have a keen edge on the sides, two 



GUM-LANCET. 



355 



or three lines from the extreme point. It is some- 
times made with the edge square ; but the round 
edge is the better form. The edge is parallel with 
the handle in the ordinary lancet. (Fig. 82.) This 

Fig. 82. 




form is used for separating the gum from the buccal 
and palatal surfaces of the tooth. A lancet with the 
edge transverse to the shaft is required for separating 
the gum from the proximal portions of the teeth. 
The blade of this should be of the same general 
form as that already described, except that it should 
be quite narrow — in no case more than two lines 
wide. (Fig. 83.) Gum-lancets are made with the 

Fig. 83. 




blade set in a socket on the end of the shaft, so that 
it can be rotated and set to any angle, to meet every 
case. 

A very ingenious instrument, invented by Dr. 
Merry, and denominated " Merry's Revolving Gum- 
lancet," has recently been brought to the notice of 
the profession. This is a very excellent instrument — 



356 EXTRACTION OF TEETH. 

superior, indeed, to any thing else of the kind. (Fig. 
84.) The following is a description of it: "It 
consists mainly of two shafts : one is round and 
small ; the other is larger, and part round, and part 
octagon. Just back of the spiral spring which curves 
down at the lancet end, is seen a piece connecting 
the two shafts. This piece is soldered fast to the 
round shaft, while the upper end of it forms a collar, 
in which the round part of the larger shaft slides 

Fig. 84. 




back and forth, and revolves. On the other end of 
the large shaft is seen a screw, made by winding a 
wire spirally round it. From the small shaft arises 
another, but shorter spiral wire, which, it will be 
seen, fits into that upon the larger shaft. The short 
one may be considered the nut, in which the other 
revolves. The ends of the short spiral are soldered 
fast to the small shaft. If, then, the large shaft is 
revolved, the screw on it playing in the nut, is 
made to slide back and forth, accordingly as it may 
be revolved. This motion, then, changes the direc- 
tion of the point of the lancet to the plane of the 
shafts, any degree from a right angle to a parallel. 
Having thus got the inclination which is desired, the 



METHOD OP LANOING THE GUMS. 35T 

blade is inserted into the gum at the point at which 
the incision is to begin ; and as the instrument cuts, 
rotate the larger shaft slightly, and the blade will 
follow the outline of the tooth as it cuts round it." 



THE METHOD OF LANCING THE GUMS. 

In all cases, the gum should be separated from the 
tooth as far as the embrace of the forceps is to ex- 
tend ; the lancet should pass close to the tooth, so as 
to make the separation clean about its neck; — in 
order to do which, the lancet must be kept in good con- 
dition; — and it should also be passed freely between 
the teeth. A complete separation of the gum is 
essential to a good hold of the forceps on the tooth. 
Some operators, however, do not use the lancet for 
this purpose, but tear the gum away by forcing the 
forceps to its position on the tooth. This method is 
objectionable on several accounts : it causes the patieDt 
much more pain than with a sharp lancet ; the for- 
ceps can not thus be adjusted to the tooth with so 
much facility ; there is far more danger of lacerating 
the soft parts, and, because of an imperfect adapta- 
tion of the forceps to the tooth, more danger of 
fracturing it ; and the operation is always more diffi- 
cult of accomplishment. In those cases in which the 



358 EXTRACTION OF TEETH. 

gum is firm and dense, and would obstruct the free 
passage of the forceps to the proper position on the 
tooth, it is sometimes necessary to make a vertical in- 
cision of the gum, even after it has been separated, 
directly opposite the root. But it is in many instances 
better to cut away a portion of the free margin of 
the gum, in the extraction of roots that are partially 
covered by it; and there is no objection to this 
method in any case where it may at all facilitate the 
operation ; for this portion of the gum, if let remain, 
is always absorbed or sloughed away after the ex- 
traction of teeth. It is also sometimes necessary 
to dissect the gum somewhat from the alveolus, in 
those cases in which a deep hold on the tooth or root 
is required, and in which the alveolus is either cut 
away or embraced by the forceps. The character and 
condition of the tooth will somewhat modify the extent 
to which the gum-lancet should be used. 

EXTRACTION OF THE TEETH. 

In the following remarks it is the design to con- 
sider only those principles obviously involved in the 
extraction of the teeth with forceps, and in the ex- 
traction of roots with forceps, elevators, and screws. 

Superior Incisors. — After an examination, the gum, 
as in all cases, should be perfectly separated from the 



EXTRACTION OF TEETH. 359 

neck of the tooth, up to the border of the alveolus : 
this is quite sufficient, if the tooth is not too much 
decayed. With the forceps already described (see 
Fig. 61), grasp the tooth firmly at the border of the 
alveolus ; introduce the instrument slowly, adjusting 
it carefully, as it passes up to the proper position : 
then, by a gradual movement, rotate the tooth in the 
socket, thus breaking up the attachment. All the 
cylindrical, single-root teeth may be luxated by a 
rotary motion. There are occasional circumstances, 
however, that render this somewhat difficult, — as, for 
instance, any considerable curvature of the root; or, 
sometimes, the attachment to the outer plate of the 
alveolus is so firm that it can not be broken up by 
rotary motion. Neither of these difficulties is usual 
with the lateral incisors ; but, with the centrals, one 
or other of them is not unfrequent. When either of 
them does occur, the attachment must be broken up 
by an inward and outward movement, which, on 
account of the pressure made on the parts, is at- 
tended with much more pain, and far greater danger 
to the contiguous parts, than the loosening by rotary 
motion. 

The roots of the incisors are not difficult to remove, 
unless, being very much decayed, they will not sus- 
tain the embrace of the forceps below the border of 
the alveolus ; and when they are thus decayed, one 



360 EXTRACTION OF TEETH. 

of the following methods may be adopted : the gum 
may be dissected from the alveolus, and the latter 
cut away with the thick cutting instrument, so as to 
expose the root sufficiently for extraction with the 
root forceps ; or, after the gum is dissected up, the 
alveolus and the root may be together embraced, and 
the former broken and removed with the latter. This 
is a rather rough method of operation, though it is 
often adopted. Or, an elevator of the proper form may 
be introduced between the root and the alveolus, and 
the root thus dislodged. 

The screw, either simple or compound, is a valuable 
instrument for the removal of these roots. But the 
gum should be separated even when the extraction 
is to be accomplished with this. The canal in the 
root should first be enlarged with a taper drill, of the 
same shape as the screw, till all the softened dentine 
is removed. Then the screw, selected of proper 
size, having a very sharp thread, is introduced till 
it takes a strong hold in the solid dentine, espe- 
cially if it is the simple screw. In some instances, 
while it is being introduced, the root will be loosened. 
In using the screw in connection with the forceps, it 
is not necessary to introduce it with the same firm- 
ness as when the screw alone is employed. In the 
use of the screw-forceps, the screw is embraced in 
the beaks, and introduced; then, the forceps are passed 



EXTRACTION OF TEETH. 361 

up on the root, or between it and the alveolus, if need 
be, the screw serving to sustain the root under the 
pressure of the forceps. The attachment of the root 
is broken by a rotary, or an inward and outward move- 
ment, as the case may require. 

Superior Cuspids. — For the removal of these teeth, 
the central incisor or the bicuspid forceps may be 
used ; though usually, the beaks of the former are too 
thin, and those of the latter, too narrow. The for- 
ceps appropriate for the removal of these teeth, have 
broad, deep, concave beaks, so as to embrace the tooth 
as completely as possible ; and they are thick, so as 
to possess sufficient strength. The gum being sepa- 
rated, and the forceps adjusted on the tooth, the at- 
tachment is broken up, either by an inward and out- 
ward, or by a rotary movement ; the former will be 
far more frequently brought into requisition, since 
these teeth are generally so firmly attached that 
they can not be loosened by the latter ; but the skill- 
ful and experienced operator will often combine the 
two, with the happiest effect. These teeth have 
larger roots than any others in the mouth, and the 
alveolar process, especially the outer plate, closely in- 
vests them ; and thus they are very firmly fixed in 
the sockets, and are also more frequently found curved 
than the roots of the incisors. Often, in extraction 
of the cuspids, a portion of the outer wall of the aire- 



362 EXTRACTION OF TEETH. 

olus is broken off, and comes away with the tooth. 
But this accident is not attended with any serious 
results ; indeed, in the preparation of the mouth for 
artificial teeth, it is desirable that it be broken away 
somewhat. 

The movement in the extraction of a tooth should 
always be very deliberate — never sudden and violent. 
A very good criterion in regard to the rapidity of 
movement, is, that the eye should follow and dis- 
tinctly recognize every motion of the forceps, the 
tooth, and the contiguous parts. 

The removal of the roots of these teeth is far more 
difficult than that of the incisors. Frequently the 
gum has to be separated up two or three lines on the 
alveolus, and the latter broken in with the forceps, 
before the root is removed. The compound screw is 
often very valuable in the removal of these roots — 
the simple screw not commonly being of much avail, 
since the force necessary to extract the root, is gene- 
rally so great that the screw alone will not take a 
sufficiently firm hold to accomplish it. The elevator 
is not a very efficient instrument in the removal of 
these roots. 

Superior Bicuspids. — For the removal of the bicus- 
pid teeth of both sides, one pair of forceps is quite 
sufficient (see Fig. 63). These forceps are without 
any curve ; though, in a small mouth, for the second 



EXTRACTION OF TEETH. 363 

bicuspids, a slight anterior curve would be desirable, 
since it would admit the instrument to a better position 
on the tooth. These forceps properly adjusted on the 
tooth, according to the directions already given, the 
attachment is broken up by an inward' and outward 
movement, carried just to the extent necessary to 
accomplish the object; and then, traction is applied 
to remove the tooth from the socket. This applica- 
tion of the force is specially adapted to the first 
bicuspids. Rotary motion should be very seldom 
applied to these teeth, because their points generally 
terminate in a bifurcation, and it is impracticable 
thus to detach them without breaking off, at least, 
one of the roots ; and, where they do not bifurcate, 
they are so much compressed as generally to forbid 
such a force. Occasionally, however, there is but 
one root, and this is nearly cylindrical, as will be 
indicated by the cylindrical form of the crown and 
neck of the tooth ; and, in such cases, the rotary may 
be combined with the inward and outward motion. 
The root of the second bicuspid commonly has no 
bifurcation, is usually somewhat compressed; and, in 
general, the rotary motion may be combined with 
the inward and outward in its extraction. There is 
occasionally, however, some curvature to the roots of 
these teeth ; but very seldom is it sufficient to cause 
any difficulty in their removal. The skillful and 



364 EXTRACTION OF TEETH. 

experienced operator will, in most cases, determine 
very accurately the size, shape, and position of the 
roots by the peculiarities of the crown ; and the at- 
tention of the young practitioner should be directed 
very closely to this point, till he is able to arrive at 
accurate conclusions. For the removal of these teeth, 
there are forceps with thick, peculiarly-formed beaks, 
constructed to take advantage of the conical shape of 
the roots. The instrument is placed on the tooth at 
the border of the alveolus, or, if need be, a little be- 
yond it ; and then, the process having been first cut 
away, firm compression is made on the handle of the 
instrument, and thus great pressure on two sides of the 
root, — which are relatively as two inclined planes, — 
by which the tooth is forced directly from its socket, 
without either the oscillating or the rotary motion. 
This instrument is rarely ever applicable to the re- 
moval of any other teeth than the second bicuspids, 
and occasionally the central incisors, and then only 
when the roots are very tapering. The roots of the 
bicuspids, especially the second, are usually not diffi- 
cult to remove. Sometimes, however, the first bicus- 
pids have two well-formed roots, somewhat divergent, 
that are difficult to remove, especially if the decay 
has eaten away till there is little of the tooth left for 
the instrument to take hold upon. But, frequently, 
if one of the contiguous teeth is absent, a lateral 
seizure will remove the root at once. 



EXTRACTION OF TEETH. 365 

Root forceps with narrow, thin beaks, which may 
be readily forced between the root and the alveolus, 
are very valuable for the extraction of all small 
roots. 

The screw, whether simple or compound, is not ap- 
plicable to the extraction of the roots of the bicus- 
pids. 

A bicuspid will sometimes stand somewhat out of 
the true circle, and the contiguous teeth approximate 
so that it will not pass between them. In such a 
case, the principal part of the movement for its de- 
tachment should be in the direction of its inclination. 
The cuspid teeth are sometimes found in the same 
condition, and a similar applicatian of force for their 
removal is to be made ; indeed, this method is appro- 
priate to all cases where the teeth stand out of a 
proper position and the contiguous teeth impinge on 
the space. 

Superior Molars.- — The first and the second superior 
molars have each three roots, one palatal, and two 
buccal ; the palatal being the largest and longest, 
and the anterior buccal larger than the posterior. 
The palatal root diverges very considerably from the 
axis of the tooth ; while the buccal are often parallel 
with it and with each other; but they sometimes 
diverge in both directions. Occasionally, the diver- 
gence of some or all of these roots, is so great that 



366 EXTRACTION OF TEETH. 

they can not pass out of the socket without either 
fracturing the alveolus or breaking off one or more 
of the roots. On the contrary, there is sometimes 
such a convergence of the buccal roots, that the inter- 
vening portion of bone is necessarily brought away 
with the tooth. Indeed, the three roots are some- 
times found all in contact, forming an irregular conical 
root; but this is a condition of unnatural develop- 
ment. 

The appropriate forceps being firmly fixed on the 
tooth, an outward and inward movement is applied, 
and traction at the same time. In the examination 
of these teeth, to ascertain the force necessary for 
their removal, two particulars have to be considered ; 
the firmness of the attachment, and the position and 
inclination of the roots. When these teeth, as they 
occasionally do, stand somewhat outside of the cor- 
rect position, great care must be exercised in their 
removal, especially if the contiguous teeth impinge. 
In small mouths, the contiguous impinging tooth is 
liable to be injured by the pressure in extraction ; but 
this injury may be avoided by directing the pressure 
backward. Commonly, the first effort made to break 
up the attachment, should be outward ; except where 
the tooth stands inside of the circle, or where it is 
decayed very much on its inner side, while its outer 
remains firm. In those cases in which the roots 



EXTRACTION OF TEETH. obi 

diverge so much that they will not pass out of the 
socket, without tearing away some of the wall of the 
alveolus, it would be impossible to break up the'.-at- 
tachment by an inward movement; for the palatal 
roots brace the tooth, and the inner process is very 
strong and unyielding. Where a molar is decayed 
on its proximal sides, and the contiguous teeth en- 
croach on it, so that it can not pass out directly be- 
tween them, it must either be cut away with the 
chisel or file till it is small enough to pass out or 
be drawn from between them. 

The decay on the buccal or palatal sides often ex- 
tends below the gum, and even below the border of 
the alveolus ; or there may be extensive softening of 
the dentine of the crown; and in either case, the gum 
and process must be cut away sufficiently to admit a 
firm hold on the root where it is strong enough to sus- 
tain the embrace of the forceps. 

Extraction of Roots. — The extraction of the roots 
of the superior molars is not attended with much 
difficulty when they are separated by decay, or are 
easily broken apart ; the method then is the same as 
for single roots. They should be deeply embraced 
with the curved, sharp-pointed root forceps (see Fig. 
68), and rotated to break up the attachment, trac- 
tion being applied at the same time. It is very 
rarely necessary to resort either to the elevator or to 



368 EXTRACTION OF TEETH. 

the screw for the removal of these roots. The 
greatest difficulty is experienced when the bifurca- 
tion is deep, and the roots all adhere firmly together. 
In such case, the same force is required for their 
removal as before the crown was decayed off. The 
root forceps, shown in Fig. 65, can be very effect- 
ively used in the extraction of these roots. The 
round, sharp beak is passed between the buccal roots, 
the other beak embracing the palatal ; and with this 
hold, by an inward and outward movement, the root 
is removed. These forceps are not applicable where 
there is but one large conical root. For the removal 
of roots of this form, the wisdom-tooth forceps, or 
those with similar beaks, are required. When it is 
necessary to dissect off the gum, and cut away the 
process, in order to obtain a firm hold of the root, this 
should be done in preference to crushing in the pro- 
cess with forceps — except, indeed, it may be the case 
of a very irritable patient, who will not tolerate a pro- 
tracted operation ; in which case, it is better to com- 
plete the operation at a single effort. 

REMOVAL OF THE SUPERIOR DENTES SAPIENTLE. 

There is not usually much difficulty attending the 
extraction of these teeth. The appropriate forceps 
for this purpose (see Figs. 66 and 71) have two large 



REMOVAL OF THE DENTES SAPIENTLE. 369 

single-concave beaks, so formed as to embrace the 
neck of the tooth, without any reference to the bifur- 
cation or the number and position of the roots. 
Ordinarily, the attachment of these teeth is broken 
up by the inward and outward movement ; but where 
a single, round, conical root is clearly indicated, the 
rotary movement would be preferable, or the rotary 
in conjunction with the inward and outward. These 
teeth sometimes stand out of the true position, more 
frequently inclining outward, as already suggested in 
another place ; and the direction of the force for 
their extraction will correspond with this inclination. 
Sometimes these teeth are very difficult to extract; 
and this difficulty is dependent on the following cir- 
cumstances : first, an anterior inclination of the tooth, 
so that it stands at a considerable angle with the 
adjoining tooth, and in contact with its posterior 
proximal surface, the posterior border of the process 
being thick and firm, and extending down full on 
the crown of the tooth ; and second, the existence of 
several roots, with great divergence, irregularity, 
and curvature. The removal of a tooth in the first 
of these conditions is often a very protracted opera- 
tion, fraught with much pain to the patient and con- 
siderable labor to the operator. Such preparation 
must be made, as will permit a free egress of the 
tooth from the socket, before an effort is made, lor its 



370 EXTRACTION OF TEETH. 

extraction. This is effected either by cutting away 
the portion of ]Drocess behind the tooth, so that it 
may be forced backward sufficiently to let it pass out 
of the socket, or by cutting away enough from the 
anterior portion of the tooth ; or, if the posterior 
proximal surface of the second molar is decayed, it 
may be quite as well, and more convenient, to cut this 
down so as to permit the ready removal of the tooth. 
Physic's forceps can be used very effectively for 
the extraction of these teeth, when they occupy such 
a position, provided the root is straight, or has a pos- 
terior curvature ; but if there is an anterior curvature, 
the tooth is most difficult to extract, and Physic's 
forceps would be wholly inefficient — except to break 
off the tooth. In such case, the posterior portion of 
the process should be cut away as much as possible. 
Physic's forceps are frequently employed for the 
removal of these teeth, when they occupy a correct 
position; but their use is somewhat objectionable, 
especially in the following respects : the instrument 
acts first on the principle of a wedge, being forced 
between the teeth ; and then on that of a lever, the 
second molar being the fulcrum ; and hence, when it 
is employed, the second molar must always be pre- 
sent, and it is liable to injury from the pressure which 
may do violence to the periosteum, or fracture and 
scale off portions of the enamel. But if the first 



INFERIOR INCISORS. 371 

molar is absent, there is almost as much liability, 
with the Physic's forceps, of loosening the second as 
of extracting the third. Indeed, it is always objec- 
tionable to use a sound tooth, under any circum- 
stances, as a fulcrum for an extracting instrument. 

A wisdom tooth the roots of which are irregular in 
number, inclination, and curvature, should be grasped 
firmly, and an oscillating force applied, sufficient to 
remove it from its socket. There is nothing per- 
taining to the removal of the roots of these teeth that 
involves any different principle or application of in- 
struments from that given for the removal of the teeth 
themselves. The anterior inclination which so often 
renders the whole tooth difficult of extraction, very 
seldom affects the removal of the roots. These are, 
in general, easily extracted with the common curved 
root-forceps. 

EXTRACTION OF THE INFERIOR INCISORS. 

In the extraction of these teeth, either of the for- 
ceps described for the purpose, may be employed. 
The beaks should be quite narrow and thin (see Fig. 
67). The instrument well fixed on the tooth, the 
attachment is broken up by an inward and outward 
movement, the rotary being seldom applicable, since. 
in general, the roots are flattened, and in many cases 



372 EXTRACTION OF TEETH. 

quite thin, so as to be incapable of turning in the 
socket. Care must be exercised in the oscillating 
movement, and especially where the tooth to be ex- 
tracted stands out of the proper position, and the con- 
tiguous teeth incline together; though this is of little 
consequence where the teeth are all to be removed. 
"When the crowns of these teeth are short and thick, 
the roots are shorter, thicker, more conical, and more 
nearly cylindrical; and. in the extraction of such, the 
rotary may be combined with the oscillating move- 
ment, 

There is seldom any superadded difficulty in the 

removal of the roots of these teeth, the same instru- 
ments and movements being applicable as for the 
removal of the teeth themselves. The only dif- 
ference in any respect is, that where the teeth are 
decayed off far down, the forceps should be forced 
down on the process, in order to obtain a firm hold 
on the root. Xeither the elevator nor the screw is 
ever required for the removal of these roots. 

INFERIOR CUSPIDS. 

These teeth may be removed with the inferior bicus- 
pid forceps of the right side ; though an instrument 
of the same general form, but of less curvature would 
be preferable, since with such, the required movement 



INFERIOR CUSPIDS. 373 

for breaking up the attachment could be more easily 
given. They commonly have long, round, conical 
roots, not so large as those of the superior cuspids, 
nor so difficult to extract — seldom having any curva- 
ture, and thus being susceptible of detachment by the 
rotary motion. They often stand so much anterior 
to the true circle, that an attempt to thrust them 
inward, would be liable to break or loosen the lateral 
incisors. Their situation, as indeed that of all teeth, 
should be strictly attended to before any attempt is 
made to remove them. 

The crowns of these teeth decay off, and leave the 
roots standing, far more frequently than do those of 
the superior bicuspids. But there is no difficulty in 
the removal of their roots ; and the only indication is, 
when they are deeply decayed, to pass the forceps far 
down on them, either first cutting away the process 
or embracing it,' as the circumstances may warrant; 
the former method being preferable. After the root 
is extracted, the fractured pieces of process, if any, 
should be removed. 

A long, tapering screw may sometimes be advan- 
tageously used for the extraction of these roots, when 
they are decayed so deeply that an extensive break- 
ing away of the process would be incident to their 
removal with the forceps. The elevator, however, is 
rarely ever called in requisition here. 



374 EXTRACTION OF TEETH. 

INFERIOR BICUSPIDS. 

These teeth, two in number on each side, have but 
one root each, and that generally round, or nearly so, 
and not so long as that. of the cuspids; and have less 
diameter at the neck than they. They require, in 
extraction, forceps for each side, as already described 
(see Fig. 69). They may be removed either by the 
rotary, or by the inward and outward movement, or 
both combined. With the handle of the forceps 
thrown very far out of a line with the axis of the 
tooth, it is always more difficult to be rotated 
accurately in its socket; a straight instrument is best 
for the rotary motion. In the removal of these teeth 
from the right side, when the mouth is small, care 
should be taken that too much pressure is not made 
against the anterior tooth. This accident is more 
liable to happen in the removal of the second bicus- 
pid, than in that of the first, and especially if the 
mouth can not be opened wide. As the tooth comes 
out, the forceps are liable, without some attention, to 
strike the superior teeth, and in this way fracture 
them or scale off their enamel. In many cases, for- 
ceps with a forward and an outward curvature com- 
bined, would be very desirable, for facility of ap- 
proaching the tooth; but with such a complication 
of curves, the operator loses control of the instru- 
ment. 



INFERIOR MOLARS. 375 

Iii the removal of the bicuspids of the left side, 
there is little or no liability to undue pressure against 
the anterior teeth ; and in their extraction, the move- 
ment should be mainly inward and outward, since 
the great curvature of the forceps renders a rotary 
motion very difficult and uncertain. There is also 
danger of striking the upper teeth, especially if 
the tooth to be extracted comes out with less effort 
than the operator anticipated ; an accident that some- 
times befals the most skillful and discriminating. The 
first and the second inferior bicuspids are removed 
with about equal facility. 

Occasionally, though seldom, these teeth have two 
distinct, well denned roots ; a condition that can not 
be determined by the form of the crown or by any 
other visible indication; and one tooth alone will 
sometimes be found w T ith this peculiarity. The re- 
moval of the roots of these teeth is not attended with 
much difficulty ; the main consideration being, to 
obtain a deep, strong hold on them, and then apply a 
firm, steady movement. 

INFERIOR MOLARS. 

These teeth commonly have two roots, a posterior 
and an anterior ; the latter being the largest, and fre- 
quently the longest. The roots have different incli- 



376 EXTRACTION OF TEETH. 

nations to the axis of the tooth, being in some cases 
divergent from, and in others parallel with it, and in 
others convergent, or curved together so that their 
points almost meet. The forms of the crowns will 
give some indication of the inclinations of the roots : 
if the former are short, the latter are so, and vice versa; 
if the diameter of the crown is about the same at the 
masticatory surface and the neck, the roots do not 
diverge ; if the crown is long and of uniform diam- 
eter, the roots will be either parallel or convergent; 
and if the angles on the crown are not sharp and well 
defined, the roots most probably curve together at 
the points. If, however, the angles formed by the 
masticatory and lateral surfaces of the teeth are sharp 
and well defined, the roots generally diverge. 

Forceps adapted to each side are required for the 
removal of these teeth. These forceps have a promi- 
nence, or point, in the center of the beaks, to pass 
into the bifurcation; and, in separating the gum, it is 
important to dissect it away, and, if need be, even 
cut away the margin of the process, so that the bifur- 
cation may be well exposed, to admit the forceps to 
a proper position on the tooth, without obstruction. 
The tooth being firmly grasped in the proper manner 
by the forceps, is moved gradually, but steadily, 
inward and outward, to break up the attachment, 
and then drawn from its socket. In the removal of 



INFERIOR MOLARS. 377 

these teeth from the right side with the ordinary for- 
ceps, there is great clanger of undue pressure on the 
anterior contiguous teeth ; which is to be avoided by 
directing the pressure backward in the operation. 
And there is also danger of injuring the upper teeth 
with the forceps ; which may be obviated by wrap- 
ping the point of the instrument with a small napkin. 

In the removal of the inferior molars of the left 
side, the application of force is the same — an inward 
and outward movement — but the handles of the for- 
ceps occupy different relative positions to the teeth 
to be extracted ; passing directly out at the front of 
the mouth, instead of at one side. In consequence 
of this arrangement, the operator can not exert the 
same force on them, as, with the proper forceps, on 
those of the right side. Yery little traction can be 
employed in connection with the oscillating move- 
ment, but the attachment must be almost wholly 
broken up before beginning to lift the tooth from the 
socket. But in extracting the teeth on the right 
side, with the proper forceps, traction is always com- 
bined with the inward and outward movement. 

In the extraction of the roots of these teeth, little 
difficulty is experienced after the decay has pro- 
ceeded so far as to effect their separation. They are 
then embraced with the appropriate forceps, and 
removed as single roots are elsewhere. These for- 



378 EXTRACTION OF TEETH. 

ceps have narrow, thin, sharp beaks, turned to almost 
a right angle. With them, the root is embraced, and 
moved inward and outward till loosened, and then 
removed. When the mouth is large, and can be 
opened wide, the slightly curved root forceps are 
convenient, and the rotary movement may be em- 
ployed with them, if the roots are not very much 
curved, flattened, or firmly set The removal of 
these roots is more difficult when the bifurcation is 
low down, and the roots remain firmly attached 
together, and especially when they diverge. If the 
bifurcation is not too low, and the attachment not too 
firm, the roots may be separated with the separating 
forceps (Fig. 85), and then removed singly, as in 
other cases. This is the preferable method, when 

Fig. 85. 




there is much divergence ; but if the fangs can not 
be separated, they may be extracted with the forceps 
shown in Fig. 74. The round, curved, sharp beaks 
are passed down between the roots, and the whole is 
removed at once ; the attachment being broken up on 
the principle already described. 

These teeth sometimes have but one, large, round, 



INFERIOR DENTES SAPIENTIiE. 379 

conical root; and there is seldom, if ever, enough 
curvature of the roots to render extraction difficult. 
The ordinary inferior-molar forceps arc not well 
adapted to the purpose : for the central points of 
their beaks will prevent a perfect adaptation. The 
broad, single-concave beaked forceps are best adapted; 
the curves and general forms of which, except the 
beaks, are the same as those represented in Fig. 71. 
The removal of teeth having this kind of roots is 
easily accomplished. Rotary movement would be 
applicable here, if the exact form of the root could be 
ascertained before extraction; but it is, in general, 
the safest course to employ the inward and outward 
movement. 

INFERIOR DENTES SAPIENTLE. 

These teeth require, for their removal, the broad, 
single-concave beaked forceps, the beaks curved at a 
right angle with the handle, and the handle straight. 
This instrument fixed deeply and firmly on the tooth, 
the attachment is to be broken up by the inward and 
outward movement. These, more frequently than 
the superior dentes sapienticv, stand out of the proper 
position ; their variations and the manner of obviating 
the attendant difficulties, however, being about the 
same — at least, so far as deviation is concerned. 



380 EXTRACTION OF TEETH. 

Physic's forceps may be used here with greater 
facility than on the upper teeth. 

These teeth frequently exhibit but a very small 
portion of the crown through the gum. Being 
erupted with an anterior inclination, the tooth comes 
in contact with the posterior portion of the second 
molar, and is thus checked in its external develop- 
ment. Thus the crown is left partially covered with 
the gum, which frequently inflames, and even sup- 
purates, remaining in that condition for a consider- 
able time, to the great annoyance of the patient. 
Such teeth are difficult to remove ; first, because of 
their inclination and contact with the second molar ; 
and secondly, because the crown is more than half 
below the borders of the thick, firm alveolus, render- 
ing it impossible to obtain a firm hold of the tooth, 
without cutting away a portion of the alveolus. In 
such cases, it is generally best to make a free excision 
of the alveolus all round the tooth, sufficient to per- 
mit its easy removal. 



EXTRACTION PREPARATORY TO THE INSERTION OF 
ARTIFICIAL DENTURES. 

Whenever there is a number of teeth to be re- 
moved, the method and the duration of the operation 
will depend on the following circumstances: first, the 



EXTRACTION PREPARATORY TO INSERTION. 381 

number to be removed ; second, the firmness of their 
attachment; third, the patient's power of endurance ; 
and fourth, the manner in which the immediate parts 
are affected. Where the number to be removed is 
considerable, and the attachment feeble, or not very 
firm, and the patient's power of endurance good, 
the extraction may be as rapid as is consistent with 
efficiency. In many such cases, from three to six 
teeth may be removed, without any relaxation, by 
the operator, of his hold on the parts with the left 
hand. This is generally practicable with the front 
teeth of the lower, and frequently with those of the 
upper jaw ; but it is not proper to remove more than 
three or four of the molar teeth, without respite, even 
when they are quite loose, or have but a feeble 
attachment in the socket. The gum should, of 
course, be well separated previously to the operation. 
Only so many teeth should be removed at one sitting 
as the nervous system will allow without too great a 
shock. In many instances, however, it is practicable 
so far as this is concerned, to remove at once all the 
teeth in the mouth. In the extraction of a large 
number those most easily removed should be first 
taken, so as by degrees to bring the patient to the more 
severe operations. If there is a manifest hemorrhagic 
diathesis — a disposition to bleed freely from the capil- 
laries, as well as from the larger vessels — but two or 



882 EXTRACTION OF TEETH. 

three teeth should be removed at a sitting, lest uncon- 
trollable hemorrhage ensue. 

After all the teeth are removed from one or both 
of the jaws, the gums and alveolus should undergo a 
trimming process : all detached, flabby, or prominent 
portions of the gums should be dissected off; the 
whole ridge made uniform ; all loose portions of the 
alveolus removed ; all the prominent points and sharp 
edges cut down; and the whole border of the process 
rendered as smooth and even as possible. By this 
means, the healing of the parts is facilitated, and they 
assume the desired condition and form in much less 
time, and with far less soreness and inconvenience. 

CONDITIONS TO BE OBSERVED IN EXTRACTION. 

Such conditions are often found to exist in the 
system, as indicate the necessity of great care in the 
operation, or of prior treatment, or forbid the extrac- 
tion of the teeth altogether. Of these conditions, the 
following are some of the more obvious : 

Extreme debility. 

Great nervous irritability. 

Excessive local inflammation, especially where it 
tends to the other parts. 

Much irritability of the parts intimately connected 
with the teeth. 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 383 

Pregnancy, and all uterine irritations. 

A tendency to epilepsy. 

In many cases, where there is great debility, so 
painful an operation as the extraction of a tooth, will 
cause extreme, and sometimes alarming prostration. 
This, however, may be anticipated, by prior invigo- 
rating treatment, continued till strength and tone are 
obtained sufficient to endure the operation. This 
treatment may occupy considerable time ; while an 
urgent case may arise, in which the removal of the 
offending tooth is immediately demanded ; in which 
case, it is proper to administer stimulants — -brandy or 
wine, or such as the case may seem to require. By 
such means the system may be so invigorated as to 
withstand the shock of the operation with compara- 
tive fortitude. 

There is in some cases a highly irritable condition 
of the nervous system, that almost absolutely forbids 
the extraction of teeth, convulsions being sometimes 
produced, in such cases, by a simple operation. This 
remark does not of course apply to facial neuralgia 
that may be either partially or wholly produced and 
kept up by diseased teeth ; neither general nor local 
neuralgia would be aggravated by an operation of 
this kind. Accompanying general nervous irrita- 
bility, there is usually excessive dread of an opera- 
tion, such as to occasion rapid prostration — even 



384 EXTRACTION OF TEETH. 

greater and more rapid than that caused by the ope- 
ration itself. In such cases, if the extraction is 
effected immediately, it will give relief; but where 
the excitement has been very high, and the tension 
for some time great, the depression after the opera- 
tion will be correspondingly great, and considerable 
time be required for complete recovery ; indeed, the 
shock is sometimes so severe as to occasion confine- 
ment for several days. Treatment for quieting the 
nervous system, consisting in agents of a sedative 
character, may be employed previously to the opera- 
tion : stimulants, as a general rule, should be avoided. 

Where there is a high state of inflammation in the 
immediate parts, especially if there is a general in- 
flammatory diathesis, the propriety of extracting the 
teeth is questionable. Under such circumstances, 
there is probably less danger in the extraction of the 
inferior teeth, than of the superior. Where the in- 
flammation has a disposition to extend, it is liable to 
go to the head from the superior maxilla, and to the 
fauces and throat from the inferior. In cases, then, 
where there is excessive inflammation in the imme- 
diate parts, accompanied by a general inflammatory 
condition, both local and general antiphlogistic treat- 
ment should be adopted. 

Extreme irritability, or a diseased condition of 
parts having an intimate connection with the teeth, 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 385 

as the immediate surrounding tissues, the salivary 
glands, and the throat, is a circumstance admonishing 
to great caution in the extraction of teeth, especially 
when such condition does not depend on the teeth 
for its exciting cause or modifying influence. It is, 
however, very generally the case, when any of the 
parts having an intimate relation with the teeth, 
become in any way affected, diseased teeth will exer- 
cise an injurious influence on them. If the necessity 
for the removal of the offending tooth is not too urgent, 
the parts that may be diseased about it, should be 
brought to as good a condition as possible. 

Pregnancy and uterine irritation frequently pro- 
duce strong sympathetic influences on the teeth, and 
especially on those which are in an irritable condi- 
tion : even sound teeth may be thus affected, so as to 
occasion great annoyance. Such teeth are frequently 
presented for extraction; but these cases should 
always be thoroughly examined before deciding as to 
the propriety of an operation. As a consequence of 
this sympathetic connection between the teeth and 
the uterus, the latter, when in an irritable condition, 
is very liable to be affected by any special violence 
to the former. In many cases, under such circum- 
stances, the extraction of a tooth is attended with 
pain in the uterus; and in cases of pregnancy, whore 
there is debility of the parts involved, abortion is 



386 EXTRACTION OF TEETH. 

liable to follow the operation. It is the duty of the 
patient, under such circumstances, to notify the ope- 
rator of the condition; or, if the latter has any know- 
ledge of it, it is his duty to become fully acquainted 
with the circumstances, and then to conform to the 
indications. In such case, treatment will avail but 
little to prepare the system for the operation. The 
better method is to adopt palliative treatment; which, 
if the affection is wholly sympathetic, must be 
directed to the organ producing the difficulty. But 
if the affection is in part local, then topical treatment 
is also indicated. When there is a suppression of 
menstruation, there will be an increased disposition 
to hemorrhage ; and in the extraction of the teeth of 
a patient of hemorrhagic diathesis, this is a point to 
which observation should be very specially directed : 
here, of course, a remedy for the obstruction would 
meet the difficulty. 

Persons subject to epilepsy should be very cau- 
tiously treated in all operations on the teeth, and 
most especially in their extraction. It is not pro- 
bable, however, that an operation of this character 
would increase the tendency to epilepsy ; but any 
undue excitement is liable to produce a paroxysm of 
the disease ; and hence the operator should proceed 
to his work with as little parade as possible; yet, not 
stealthily ; the patient should be thoroughly aware of 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 387 

what is to be done ; for, of all patients, such a one is 
the last that should be deceived. Of course, in a case 
of this kind, there can be no prior treatment that will 
avail anything; the most that can be done is, to await 
the fittest opportunity in respect to the paroxysms. 
There is no more liability to fatal results with such 
patients than with others. 



CHAPTER XII. 

ACCIDENTS IN THE EXTRACTION OF TEETH. 

The accidents liable to occur to the teeth and the 
contiguous parts in the operation of extraction, were 
formerly far more frequent than at present. This 
results from the existence of more perfect instru- 
ments and of more accurate and extensive knowledge. 
Formerly, very few studied the peculiarities of the 
teeth, either in their physical or anatomical struc- 
ture ; their peculiar forms, as indicated by their 
crowns ; their anatomical and physiological relations 
to the contiguous parts and to one another ; and their 
attachment as affected by the character and structure 
of the tissues about them. The instruments em- 
ployed, too, were, till within a few years past, very 
crude in their forms, very inapplicable in that part 
which embraces the tooth, inappropriate in their 
shapes, and defective in their manner of applying the 
force in the operation. But these causes of accidents, 
so far as the better part of the dental profession is 
concerned, have been in a very marked degree dimin- 
ished. 



HEMORRHAGE. 389 

Some of the accidents attendant or consequent on 
the extraction of teeth, are of a grave character. 
Permanent deformity has sometimes been occasioned 
by extensive laceration of the soft parts, or by frac- 
ture of the alveolus and of the maxilla. Intense 
and protracted suffering frequently, and death some- 
times, follows such accidents. 

HEMORRHAGE. 

Excessive and obstinate hemorrhage in some cases 
follows the extraction of teeth, occasionally resulting 
seriously and even fatally. There is in some con- 
stitutions a hemorrhagic diathesis, so that from a 
small wound, or even a scratch, there will ensue per- 
sistent bleeding. This condition is dependent, first, 
on a lack of tone in the bloodvessels, so that they 
fail to contract at an injured or ruptured point ; and 
secondly, on a peculiar condition of the blood, such 
as to prevent ready coagulation, as, when there is a 
relative deficiency of albumin and fibrin. It is one 
of the most important duties that ever devolve on the 
dentist, to make a correct diagnosis in cases where 
there is a tendency to hemorrhage. Close attention 
to the following points, will assist much in arriving 
at a just conclusion. In persons of a hemorrhagic 
tendency, there is a lymphatic, serous temperament ; 



390 ACCIDENTS IN THE EXTRACTION OF TEETH. 

a lack of tone in the soft parts — a soft, flabby condi- 
tion ; the skin pale, and devoid of the bright, vital 
appearance; the eyes and hair of light color; and the 
flow of saliva and mucus abundant. Besides these 
indications, much may be learned sometimes by pro- 
perly directed inquiries of the patient in regard to a 
disposition to hemorrhage on being wounded, either 
in his own case, or in that of his relatives ; if in the 
former, under what circumstances ; whether from an 
extensive or slight wound ; from large or small ves- 
sels — from arteries or veins ; or, whether it occurred 
immediately, or after the lapse of some time. If the 
patient has never met with an accident sufficient 
to occasion excessive hemorrhage, and any of his 
relatives have, and a tendency to bleeding is sus- 
pected in the case, the operator should ascertain 
whether there is a similarity of temperament and 
constitutional tendencies between the patient and 
such relative. 

There are certain conditions in which excessive 
hemorrhage would be more likely to occur than in 
others ; as, for instance, when there is an accidental 
relaxation, or deficient tone, in the system, especially 
the vascular; and also, when there is a suppres- 
sion of any periodical discharges. There may be 
excessive hemorrhage from a ruptured vessel when 
there is no constitutional hemorrhagic tendency. 



HEMORRHAGE — TREATMENT. 391 

There is sometimes a local difficulty with the vessels 
— a lack of tone in the part — or an aneurismal con- 
dition — on account of which obstinate hemorrhage 
will occur. A peculiarity of this kind is not very 
readily recognized. 

Violent passion, and, indeed, any strong agitation 
of the mind, will aggravate hemorrhage. Improper 
medication, as well as highly stimulating food, will 
have the same tendency. Anything that will in- 
crease the circulation, or reduce the tone of the ves- 
sels, or change the condition of the blood, will 
increase the liability to hemorrhage. Simple deter- 
mination of blood to a part, however, would not 
indicate such a liability. When there is a special 
hemorrhagic diathesis, the blood will flow from all 
the wounded surface, will be thrown out from all the 
ruptured capillaries. The most difficult cases are 
those in which there is a defect both in the vessels 
and in the blood. If the latter is in a good condition, 
it will coagulate in ruptured capillaries, though they 
might be deficient in tone ; but in larger vessels, 
though coagulum might be formed, it would not be 
retained. 

TREATMENT. 

In cases where there is manifest hemorrhagic dia- 
thesis, prior treatment is indicated, if the necessity o( 



392 ACCIDENTS IN THE EXTRACTION OF. TEETH. 

extraction is not urgent ; and that treatment will be 
determined by the peculiar condition of the case. If 
there is a lack of tone in the vessels — an inability to 
contract — then the treatment should be of a tonic 
character ; and, if the blood is in good condition, this 
is the only treatment necessary ; but, if in a vitiated 
state, other treatment will be demanded ; the object 
of which is to produce an increase of red corpuscles, 
albumin and fibrin. It is always better to postpone 
an operation, if at all practicable, till such treatment 
can be had as will bring the system to the best pos- 
sible condition. 

Of the several methods of arresting hemorrhage, 
the proper one in a given case will be determined by 
the circumstances. Styptics, or astringents, applied 
directly to the ruptured surface, will often be found 
to produce coagulation of the blood, and thus stop its 
flow, without anything else. This kind of remedy 
will be efficient in those cases in which the applica- 
tion will produce contraction of the bleeding vessels, 
as well as coagulation of the blood. Sometimes this 
class of agents will fail to accomplish the object; in 
which case, in addition to them, compression should 
be made upon the part. Indeed, in many cases, the 
compress will effect all that is desired, without any 
other application. 

There are several methods of applying the com- 



HEMORRHAGE — TREATMENT. 393 

press ; but the one best adapted to any given case, 
will be determined by circumstances; such as the 
extent of the wound, the character of the hemor- 
rhage, the location of the injury, and the size of the 
mouth. 

A very common method of making compression in 
the socket from which a tooth has been drawn, is, to 
force into the cavity pledgets of cotton, or small 
strips of linen, tightly, till it is full. It is well to 
saturate these with a solution of tannin, or some 
astringent preparation, applying it, too, in connection 
with the compression. In some cases, a simple pack- 
ing of the cavity in this manner, is quite sufficient ; 
but, in others, it is necessary to retain the pledgets 
in the socket by means of further compression. This 
is effected by placing a roll of linen, or perhaps bet- 
ter, a properly formed piece of cork on the packing, 
and then closing the jaws tightly upon this, and, if 
need be, placing a bandage under the chin, and tying 
it firmly over the head. The length of time during 
which it will be necessary to keep the jaws thus 
together, will, depending on the nature of the case, be 
from one to six hours. After the hemorrhage has 
entirely ceased, the bandage is to be removed care- 
fully, and the patient instructed to hold the jaws 
together on the compress for a time, and then gradu- 
ally to open the mouth, and remove the cork with 



394 ACCIDENTS IN THE EXTRACTION OF TEETH. 

much caution. After this, the packing should re- 
main in the socket from one to three days, and then 
be removed very carefully, one piece at a time, lest 
the ruptured vessels be opened and the hemorrhage 
caused to recur. 

The object in applying a compress is to bring it to 
bear upon the aperture of the wounded vessel, and in 
this way to prevent the escape of blood, till coagulum 
is formed and the opening permanently closed. The 
operator should ascertain the precise point from which 
the blood flows, and form the compress so as to bear 
full upon it. If the flow is from all the wounded 
surface, then the compress must be made to conform 
exactly to that throughout. 

Another method of making the compression, is to 
force softened wax into the socket, so as to fit it per- 
fectly ; remove it and chill it in cold water; and then 
introduce and make compression upon it in the man- 
ner already described, following, throughout, the 
general directions. Another, and probably better 
method, is, to form cones of wax cloth, as near the 
shape and size of the root removed from the socket 
as possible. This material is prepared by dipping 
thin linen into melted beeswax, withdrawing it and 
letting it cool, and then cutting off strips of from a 
fourth to a half an inch wide, and rolling them to the 
proper size and shape. Having softened this material 



HEMORRHAGE — TREATMENT. 395 

by heat, and freed the socket of coagulum, introduce 
and press it firmly into place, making the compression 
on it as already directed. This makes a very efficient 
compress for many cases. 

Plaster of Paris is sometimes used on the principle 
of a compress. Having the plaster mixed of the 
proper consistence, and the cavity clear, fill com- 
pletely with it, let it set, and then make compression 
on it in the usual manner. 

The root of the tooth is sometimes returned to the 
socket to serve as a compress. It possesses the 
advantage of having a perfect adaptation. This 
method of compression may be made more thorough 
by immersing the root in melted wax, and then, before 
this becomes too hard, introducing it into its original 
position. This makes a very perfect and efficient 
compress. If the crown is still remaining, when the 
jaws are closed it will come in contact with the oppo- 
sing teeth, and thus be kept firmly in place, without 
anything further. It may be removed carefully after 
from one to three days. In cases where there is 
hemorrhage from the entire wounded surface, there 
will be a considerable flow of blood from the margin 
of the gum, even after plugging up the socket, and 
making compression by either of the methods de- 
scribed. In such case, after the socket is plugged up 
as already described, a plate is so formed as to tit 



396 ACCIDENTS IN THE EXTRACTION OE TEETH. 

tightly over the gum, and draw its margin down 
closely upon the compress. This pressure on the 
bleeding edges of the gum, checks the flow of blood 
there. The plate must be held down by the means 
already described. It is sometimes difficult to obtain 
an accurate fit for the plate, so as entirely to prevent 
the blood from continuing to ooze out. In such 
cases, make the plate to conform as nearly as conve- 
nient to the part; then fill up its concavity with 
plaster of Paris, mixed to a proper consistence ; and 
then place the whole upon the part, till the plaster 
conforms exactly to it, and retain it there till the 
plaster sets. This is then used for the compress. 
Or the inside of the plate may be thickly coated with 
softened gutta-percha, instead of plaster, and .pressed 
upon the part in the manner already described, and 
employed in the same way. 

It will often require considerable discrimination to 
determine the best method of obtaining compression. 
Very great difficulty is occasionally experienced when 
a portion of the process has been broken away, or the 
soft parts have been lacerated. 

Various preparations are used as hemostatics. 
These agents serve to check hemorrhage in two 
ways: first, by facilitating a coagulation of the blood; 
and secondly, by producing a contraction of the ori- 
fice of the ruptured vessels. It is proper in all cases 



HEMORRHAGE — TREATMENT. 397 

to use styptics in connection with the compress. The 
following agents have been used as styptics : tannic 
acid, creosote, nitrate of silver, chlorid of zinc, sul- 
phate of zinc, oil of turpentine, muriate of iron. The 
methods of applying these different preparations are 
the same. The agent is simply to be retained in 
contact with the part till it has exerted its influence. 
A solution of tannin in alcohol with creosote, equal 
parts, makes a very powerful styptic ; or tannin and 
creosote alone is perhaps equally efficient. 

The actual cautery is sometimes used to arrest 
hemorrhage ; but the propriety of using it in cases 
where there is a manifest hemorrhagic diathesis, is 
exceedingly doubtful. When the cauterized surface 
is sloughed off, the hemorrhage is liable to recur with 
increased vigor, indeed, is certain to do so in almost 
every case when there is a strong predisposition. 
Constitutional treatment may be employed to antici- 
pate hemorrhage; and it should have in view an 
increase of the relative amount of red corpuscles, 
albumen and fibrin, in the blood ; and also the pro- 
duction of a normal tone of the system. Saline purga- 
tives may be used with very decided advantage, 
followed with acetate of lead, in connection with 
opium ; the effect of the lead being to increase the 
coagulability of the albumen and fibrin. Care should 
be exercised, however, in its administration. 






398 ACCIDENTS IN THE EXTRACTION OF TEETH. 

Excessive hemorrhage will sometimes occur from 
very slight wounds ; death has been known to ensue 
from simply scarifying the gums. Mr. C. desired 
the removal of the first superior molar. The gum 
was separated from the neck of the tooth with the 
lancet, in the usual manner, when he refused to have 
anything further done, and left the office, there being 
a slight discharge of blood from the gum. After a 
few hours, the hemorrhage increased so as to cause 
alarm to the friends. The patient was some eight 
miles from a dentist, and a physician of rather mode- 
rate skill was called to the case. He probably acted 
according to his best knowledge, but failed to arrest 
the hemorrhage, and succeeded in convincing the 
friends that no one else could do better. The flow 
of blood continued three to four days, proving well- 
nigh fatal, but at last abated, and the patient recov- 
ered. In this case, a properly directed compress would 
have checked the bleeding in a few minutes. 

Another case : Mrs. T. had nine teeth removed. 
The operation was not followed immediately by un- 
usual hemorrhage ; but, within two or three hours, 
the flow of blood had increased to an alarming extent, 
so as to run from the mouth in a continuous stream. 
The indications were that the patient w 7 ould soon die. 
She had become very weak. On examination, the 
blood was found issuing only from the socket of one 



HEMORRHAGE — TREATMENT. 399 

root of an inferior molar. The mouth and socket 
being cleansed of blood and coagulum, it was perceived 
that the hemorrhage was from a small artery at the 
bottom of the socket, spouting out in jets with the 
pulsations. The treatment consisted in rolling up 
pledgets of cotton very tightly, saturating them with 
creosote and tannin, and forcing them in on the bot- 
tom of the socket, so as to make compression upon 
the bleeding vessel. The socket was then filled up, 
compression made, and the head bandaged in the 
manner already described. Thus the hemorrhage 
was immediately checked, and did not return. The 
constitution of this patient was of a scorbutic dia- 
thesis. 

Excessive bleeding often does not occur till con- 
siderable time after an operation ; and it may come 
on without any exciting cause, or be induced by 
vigorous muscular exercise, or by any intense mental 
excitement. Everything of this kind should be 
avoided, where there is a predisposition to hemor- 
rhage, and everything invited, that would tend to 
maintain the equilibrium of the circulation and the 
utmost quiet. 



400 ACCIDENTS IN THE EXTRACTION OF TEETH. 
FRACTURE OF THE ALVEOLUS. 

The ordinary fracture of the alveolus is a matter 
of no considerable consequence, if it receives proper 
attention. This fracture occurs to a greater or less 
extent under the following circumstances: first, when 
there is great divergence of the roots, so that the 
tooth can not pass from its socket, unless one or more 
of them are broken off, or the alveolus fractured ; 
second, where the tooth is forced out of the socket at 
a very considerable angle with its axis ; third, where 
the alveolus is very firmly attached to the roots, and 
is very thin toward the points of these. Usually, the 
fracture is of that part which forms the socket of the 
tooth removed ; and when this is the case, it is of 
but small moment. It sometimes, however, extends 
far beyond this, involving the alveolus of from one to 
four of the adjacent teeth, and causing very serious 
injury, even the loss of the teeth themselves. Ex- 
tensive fracture, however, is far less liable to occur 
now, than when less perfect instruments were em- 
ployed. When the key was in general use, extensive 
fracture of the alveolus was frequent; but with the 
forceps, it is comparatively rare. 

When an accident of this kind does occur, all of 
the detached portion, whether large or small, should 
be removed. A pair of bone nippers, or enucleating 



FRACTURE OF THE ALVEOLUS. 401 

forceps will answer for this purpose. If there is much 
attachment to the soft parts, it should be dissected 
off, and then removed. If such fractured portions 
are permitted to remain, inflammation, and oftentimes 
sloughing of the gums, will ensue; necrosis of the 
bone is also sometimes produced by detached bone 
remaining in contact with the living. 

Sometimes extensive fracture occurs, involving the 
adjacent bony structure. In the case of Mr. W., in 
an effort to remove the first superior molar, the outer 
wall of the alveolus was separated from the other 
teeth. The fracture extended almost to the zygo- 
matic process, and detached a portion of the floor of 
the antrum, as well as a part of its outer wall. After 
the removal of this detached portion, there was a 
considerable external depression, that very much 
marred the form and symmetry of the face. 

Fracture of the alveolus should always be guarded 
against as carefully as possible. It always makes an 
unfavorable impression, on the mind of the patient, 
which in many cases no explanation can obliterate. 
Whenever the accident does occur, the disagreeable 
knowledge of it may, if practicable, remain a secret 
with the operator. 



402 ACCIDENTS IN THE EXTRACTION OF TEETH. 

LACERATION OF THE GTJMS. 

The gums are often bruised and lacerated with the 
key in the extraction of teeth. But this accident 
seldom happens with the forceps; indeed, never, un- 
less the gum is very firmly attached to the neck of 
the tooth, and has not been separated with the lan- 
cet. The gum will sometimes be lacerated by adher- 
ing to a piece of the process, while the tooth is drawn 
from its socket, with the process and gum attached. 
With the various hooks and punches, the gums^ lips, 
and cheeks are sometimes wounded. Accidents of 
this kind are to be prevented by placing a ringer of 
the left hand, or a guard made of a roll of linen, in 
front of the instrument. When any considerable 
portion of the gum is lacerated, the detached portion 
should be cut off. The worst consequences from 
laceration of the soft parts occur where there is a 
hemorrhagic diathesis. The most effectual means 
«of preventing accidents of this kind is to separate the 
gum perfectly, and guard well the points of the 
instrument. 

BREAKING THE TEETH. 

This is an accident of no small consequence, and is 
liable frequently to occur in the use of imperfect, ill 



BREAKING THE TEETH. 403 

adapted instruments, or in the unskillful use of good 
ones. It is of very common occurrence when the key 
is employed for extracting, even in the hands of those 
who claim to be skilled in its use. And with forceps, 
too, of the primitive form, the teeth were so fre- 
quently broken, as almost to preclude their use as 
extracting instruments. This accident usually occa- 
sions great pain to the patient, as well as protracts 
the operation, and diminishes his confidence in the 
ability of the operator. One s*uch accident will 
create more prejudice than fifty skillful operations 
can obliterate. 

In all cases where a tooth is broken, the root, if 
possible should be removed; for, if it be not, con- 
tinuous or periodical pain, inflammation, alveolar 
abscess, and like affections, are liable to ensue. 
The remark is often made, when teeth are broken, 
that the gums will close over the roots and thus 
effectually protect them, and no disagreeable conse- 
quences will follow. In no ordinary case will the 
gums unite over even the smallest portion of root 
that may have been left in the socket. 

REMOVAL OF A WRONG TOOTH. 

There is very rarely any excuse for the removal of 
a sound, healthy tooth in the immediate vicinity of a 



404 ACCIDENTS IX THE EXTRACTION OF TEETH. 

diseased one, unless it be in a case of those deep- 
seated, hidden affections which are difficult to diag- 
nose. It sometimes happens, however, that a sound 
tooth is removed; and when a mistake of this kind 
is made, the diseased tooth should also he at once 
removed, and then, if the conditions are favorable, 
the healthy one should be immediately replaced. 
The circumstances most favorable for such replace- 
ment, are, a good constitution in a state of health, 
and a normal condition of the mouth, especially of 
the gums and mucous membrane, so that the attach- 
ment would take place with as little inflammation 
and soreness as possible. If the tooth is necessarily 
kept out of the mouth many minutes, it should be 
placed in water at about blood heat: and before the 
replacement, the socket should be thoroughly cleansed 
of coagulum. The tooth is then introduced, pressed 
firmly to place, and allowed to remain without dis- 
turbance or irritation, till the attachment has become 
complete. During the time it is reuniting, treatment 
may be required to counteract inflammation. Meager 
diet, abstinence from stimulants, and quiet, should 
always be recommended in the case. 

This operation has been wholly condemned by some 
very g:od dentists. Dr. Koecker declares that it 
should never be attempted. But numerous success- 
ful cases, well attested, give assurance that it may 



REMOVAL OF A WRONG TOOTH. 405 

very frequently be accomplished with the most satis- 
factory results. Mr. T., aged 15 years, of.good consti- 
tution, and in good health, and with the mouth princi- 
pally in a normal condition, had the second inferior 
bicuspid of the left side removed by mistake, the first 
molar being the offending tooth. The former was at 
once put into cold water, and the latter forthwith 
extracted. The socket of the bicuspid was then 
cleansed, and the tooth replaced. There was slight 
soreness for a few days, after which the tooth was 
found to have made a firm and permanent reattach- 
ment; and from that time to this — twenty-five 
years — it has remained perfect, and is now as healthy, 
lifelike, and valuable as any other tooth in the mouth. 

Since the issue of the first edition of this work* 
many cases have come under the observation of the 
writer, in which detached teeth have been replaced, 
and become as firmly fixed in the sockets as before re- 
moval, and remained in apparently a healthy condition 
so far as the attachment is concerned. In some of 
these cases very unfavorable conditions were present. 

So numerous and successful have these cases been, 
that the feasibility of replacing teeth that have been 
improperly removed, is a matter no longer to be con- 
troverted, and especially when favorable conditions 
exist — good health and tone, both general and local. 
and the parts involved not too much fractured and 
lacerated. 



406 ACCIDENTS IN THE EXTRACTION OF TEETH. 



DISLOCATION OF THE INFERIOR MAXILLA. 

The dislocation of the inferior maxilla is an acci- 
dent of not very frequent occurrence. In persons of 
lax muscles and with large mouths, the operation of 
extracting teeth is liable to produce it; sometimes 
when the operation is on the upper jaw, but more 
frequently when it is on the lower. In the former 
case, it is an effect of the patient's effort to open the 
mouth; but in the latter, generally that of the move- 
ment of the jaw by the instrument. The dislocation 
consists in a downward and forward movement of 
one or both of the condyles, so that they are thrown 
out of their sockets, and rest in front of the anterior 
rim. In such case, the mouth is distended to its 
utmost, the chin thrown down on the breast, and 
deglutition and speech rendered impossible. Some- 
times but one condyle will be thrown out; in which 
case the jaw is thrown downward and to one side. 

This accident seldom or never occurs with patients 
who have small mouths or firm muscles. When it 
does happen, however, the dislocation should be 
promptly reduced. Of the various methods of accom- 
plishing this reduction, the one most commonly em- 
ployed, which is very efficient, is as follows: if both 
condyles are dislocated, place corks, or some similar 






DISLOCATION OF THE INFERIOR MAXILLA. 407 

substance, between the superior and the inferior molar 
teeth of both sides; and then, with the fingers of 
both hands, make firm, steady pressure on the chin 
upward and backward, thus forcing the condyles 
downward and backward into their proper places. 
If but one condyle is out, the cork should be ap- 
plied only on that side, and in the manner already 
directed. Another method is, to substitute the 
thumbs of the operator for the corks, placing them 
in the same position between the teeth, and manipu- 
lating with the fingers on the chin, as before. The 
patient should be placed in a recumbent position for 
the operation. Another method is, to make down- 
ward and backward pressure on the coronoid process, 
and in this manner cause the condyles to glide into 
their places. This accomplishes the reduction with- 
out taking hold of the jaws, or placing a fulcrum 
between them. 

This accident is far more liable to occur the second 
time in the same case. In extracting the lower molar 
teeth for one who has suffered a dislocation, or is pre- 
disposed to it, the lower jaw should be very firmly 
supported with the left hand; or, the accident may 
be prevented by placing a bandage under the chin, 
and over the head, so that the mouth can not be 
opened to its furthest extent; and this is the surest 
method. In all cases after an accident of this kind. 



408 ACCIDENTS IN THE EXTRACTION OF TEETH. 

the patient should abstain from solid food for a few 

days, or at least till the soreness is abated, and avoid 
everything promotive of inflammation. 

SYNCOPE. 

* 

Syncope, or minting, is frequently brought on by 
extraction of the teeth, and even by other operations 
upon them; indeed, it is sometimes produced simply 
by cutting the gums, or by the sight of blood, or, in 
some instances, by dread of an operation. It con- 
sists in an intermission of the heart's action, and 
consequently irregularity of the circulation of the 
blood, accompanied with a temporary suspension of 
the functions of the brain and a loss of consciousness. 
Difficult or suspended respiration, lividness of the 
skin, and inability to move, are the external indica- 
tions of the condition. There are no constitutional 
appearances known, by which a predisposition to 
syncope can be determined : persons of all apparent 
conditions and peculiarities are subject to it. The 
most strong, robust, and healthy sometimes faint 
under the most trivial influences; while others, of 
the weakest and feeblest constitutions, can not be 
brought into this condition by any ordinary means ; 
so that nothing can be predicated of appearances as 
to such predisposition. The fainting may occur- once 
or twice in the same case, even under the most sim- 



SYNCOPE. 409 

pie operation, owing to some temporary condition of 
the system, and never happen again under any cir- 
cumstances whatever. 

It sometimes comes on before, sometimes after, and 
sometimes during, the operation. There is greater 
liability to it after a recent meal than after digestion 
is completed, since the nervous energy, during diges- 
tion, is directed to the stomach and its appendages, and 
thus the circulating apparatus has less of nervous force. 
The frequent occurrence of syncope indicates a 
constitutional predisposition to it, and may enable 
the operator to anticipate it to some extent, by the 
aid of stimulants, such as brandy, or, what is in 
some respects preferable, a galvanic current. The 
patient subject to such affection, should be placed, 
for an operation, as nearly as practicable in a recum- 
bent position— especially for the extraction of teeth — 
and his mind kept as tranquil as possible. 

To restore the patient from syncope, place him in 
a horizontal position, the head quite as low as the 
body, and apply volatile stimulants to the nostrils. 
and dash water on the face and chest. All compres- 
sion should be removed from the body, especially 
from the chest, as it would constrain the action of 
the respiratory muscles. This remark is peculiarly 
applicable to female patients. This treatment will 
usually be quite sufficient to effect a rapid reaction 
and resuscitation. 



CHAPTER XIII. 

ANESTHETICS. 
ETHER CHLOROFORM NITROUS OX IDE . 

Sulphuric ether was the first agent successfully 
employed for producing insensibility to pain during 
surgical operations. It was brought to the notice of 
the profession in 1846 by the late Dr. Horace Wells, 
of Hartford, Conn. 

The mode of administering it is, by inhalation of 
the vapor; and it produces its effects in a short time, 
depending on the quality of the ether, the amount of 
air introduced with it, and the susceptibility of the 
patient. A complicated instrument, denominated an 
inhaler, was first employed for its administration; but 
it soon became apparent that this was not at all 
necessary, and that simpler methods were preferable, 
because more easily regulated and adapted to varying 
circumstances. The best method is, to inhale it from 
a sponge or napkin, since, in this way, the admission 
of the air can be controlled entirely by the will of the 



ETHER — CHLOROFORM. 411 

operator, graduating it to the requirements of the 
case. 

During the administration, the patient should be in 
a reclining posture; though it is held, by much good 
authority, that a horizontal position is the safest, 
because, in that, the force of the circulation is most 
nearly equalized. In the administration of general 
anaesthetics, the circulation is always more or less 
affected. It is an opinion very generally received, 
and probably correct, that, where there is functional 
derangement of the heart, lungs, or brain, general 
anaesthesia should not be employed. This opinion, 
however, is perhaps derived more from analogy than 
from actual observation. It is true that, other things 
being equal, the liability to injury in such case would 
be greater; but the danger with both ether and chlo- 
roform is, that there are cases in which there is an 
undefinable and undetectable idiosyncracy, or malsus- 
ceptibility of its influence, to a great extent indepen- 
dent of pathological conditions. 

The patient having been placed in a comfortable 
position, and his mind freed as far as possible from 
apprehension, he should be directed to breathe tran- 
quilly by full inspirations, carefully guarding against 
any compression of the chest, so as to allow the re- 
spiratory muscles free play. During the administra- 
tion of the anesthetic, a strict watch must be main- 



412 ANESTHETICS. 

tained over the patient, having reference to the fol- 
lowing points : the breathing should be free and easy, 
without irritation of the throat or bronchia; the skin 
should not become blanched, but should retain a 
florid, lively color; but the great criterion is the 
pulse, and the indications given here should be strictly 
observed and obeyed. In order that the operator 
may follow every indication, he should be familiar 
with the manifestations of the pulse in different con- 
stitutions, and under different circumstances. During 
the administration of ether or chloroform, the pulse 
usually becomes more frequent ; but it should not be 
much accelerated, nor its strength and fullness be 
much diminished. Enfeebled or irregular pulse should 
in all cases be regarded as a warning; and if the 
feebleness and irregularity be very marked, the ope- 
rator should desist. In some instances, death has 
occurred after a few inhalations ; but perhaps only in 
the use of chloroform. This fact indicates that the 
first effects of the administration should be very closely 
noted. 

The degree to which the anaesthesia should be car- 
ried, is a matter about which there is much diversity 
of opinion. Every condition of it, from that of simple 
allayed irritability to that of complete insensibility 
and unconsciousness, has its advocates. But the 
extent to which the administration may be carried, 



ETHER — CHLOROFORM. 413 

will be suggested by the indications already referred 
to, and, if these are unfavorable, should be determined 
at once. Mere nausea, however, without any other 
unfavorable symptom, is not a counter-indication in 
the use of ether or chloroform. 

The method of administering chloroform is the 
same as that for ether, except that, in the use of the 
former, more care and closer observation are required. 
Chloroform is more rapid and powerful in its action 
than ether, and hence more liable to do injury ; but, 
independently of this fact, it is generally believed 
that the former is less safe than the latter, when 
taken into the system, especially by inhalation. A 
mixture of ether and chloroform, or chloric ether — 
usually equal parts of chloroform and ether, but the 
proportions are sometimes varied — -is used by some ; 
the object being to secure greater promptness than 
with ether alone, and incur less danger than with 
chloroform ; and it is probable that a mutual compen- 
sation in these respects is thus to be attained. 

If either chloroform or ether has been administered 
to entire unconsciousness, the patient should be per- 
mitted to pass out of the condition spontaneously ; 
for, after such a revival, there will be less liability to 
unpleasant feelings, as headache, depression, and 
nausea. The fingers of the person administering the 
chloroform should be kept on the carotid, since the 



414 ANESTHETICS. 

state of the circulation will be better recognized by 
this than by the radial artery, and it is a more con- 
venient point for observation. In favorable cases, it 
is preferable to continue the inhalation till there is a 
muscular relaxation. 

When a condition arises in which respiration is 
suspended, and the circulation partially or altogether 
stopped — a condition of imminent peril — active mea- 
sures must be resorted to for the patient's restoration. 
Efforts must be directed to a recovery of the circula- 
tion, by friction, motion, etc. ; but to restore the 
respiration, is the first, immediate, imperative con- 
sideration. Any or all of the ordinary methods of 
re-establishing suspended respiration may be em- 
ployed. Cold water should be dashed in the face, 
and on the throat and chest, and volatile stimu- 
lants applied to the nostrils ; the glottis should be 
titillated with a feather, or some such implement, to 
excite it to action ; and artificial respiration, by some 
approved method, should be at once adopted. The 
galvanic current, too, may be brought into requisition, 
to excite the respiratory muscles to action, and to act 
also upon the circulation. In all cases of accident of 
this kind, prompt and efficient measures should be 
immediately taken; for a delay of a few moments 
may be attended with fatal results. 



NITROUS OXIDE. 415 



NITROUS OXIDE. 



This agent is now used as a general anaesthetic 
quite extensively in dental practice. Such has not 
been the case, however, till within the last three 
years. This agent, when properly prepared, and 
judiciously administered, is perhaps the safest general 
anaesthetic in use ; it is very efficient for minor sur- 
gical operations, and we believe will ere long be found 
to be applicable to the more protracted and graver 
operations. Its efficiency is very much modified by 
its preparation and mode of administration. This gas 
when pure is colorless, and of slightly sweetish taste 
and odor ; it is usually prepared by decomposition of 
nitrate of ammonia. 

It is not the purpose here, to describe the method 
of preparing this agent, that has been well done by 
others ; yet it is proper to suggest here, that to a 
large extent, the knowledge and opinions entertained 
on this subject have been very circumscribed, and 
exceedingly erroneous. In the administration of 
nitrous oxide as an anaesthetic, great care should be 
exercised to secure the best results. In order to 
accomplish this, it should be inhaled, and in no case 
but once, diluted as circumstances may indicate. 
more or less with pure atmospheric air ; this is ordi- 
narily necessary only at the beginning, for pure 



416 ANESTHETICS. 

nitrous oxide will sustain respiration for an indefinite 
time. 

To a patient in an anaesthetic state, it is not so 
readily administered as chloroform or ether ; but the 
patient under its influence, is quite as manageable as 
with any other agent, and the anaesthesia as perfect, 
but not as prolonged without continued administration. 

It is scarcely justifiable in ordinary dental practice 
to use a more heroic general anaesthetic than the one 
here referred to. 

LOCAL ANESTHESIA. 

Because of the frequently prejudicial and sometimes 
fatal consequences to which systemic anaesthesia is 
liable, local anaesthesia has been brought into requi- 
sition ; the first method of accomplishing this was by 

Congelation. — This was effected by the applica- 
tion of two parts of pulverized ice and one of salt, 
•applied by means of an instrument of the following 
description : a vulcanized India-rubber tube, about 
five inches long and one inch in diameter, closed at 
its superior extremity by a screw-cap, and open at its 
inferior, which latter is slightly enlarged and cut out, 
so as to leave two lips to reach down on the sides of 
the tooth ; within the tube, a follower and a spiral 
spring, the latter forcing the former down to the open 



LOCAL ANESTHESIA. 417 

end. When this instrument is to be used, tie a piece 
of oiled silk or membrane loosely over its inferior 
end, fill it expeditiously two-thirds full with the ice 
and salt, prepared as above, adjust the follower and 
spring in place, screw on the cap, and apply at once. 
The sac of the instrument is to be pressed and worked 
gradually down till it invests a portion of the gum on 
each side of the tooth to be extracted. As the ice 
melts in the sac, the follower forces the unmelted 
portion down next to the tooth and gum. The appli- 
cation should be continued from one to three minutes, 
or till the margin of the gum is congealed — as will 
be indicated by its hardness and whitened appear- 
ance — and then the tooth should be extracted as 
expeditiously as possible, though with all the ordinary 
skill and care. 

If the contiguous teeth are sound, and not to be 
extracted, they must be protected as far as possible 
from the influence of the application — as they may 
be, by having their crowns enveloped in thin sheets 
of wax, oiled silk, or any other substance that is a 
non-conductor, and is not too bulky. Where some 
such protection is not afforded, great injury is liable 
to ensue. 

If the tooth to be extracted is sensitive, the tem- 
perature should be reduced by holding in the mouth 
cold w T ater, and finally a piece of ice; and immediately 

Bli 



418 ANESTHETICS. 

after, the instrument should be applied. When the 
pulp of the tooth is exposed, the application would 
cause great pain. In such cases, it has been recom- 
mended first to apply arsenic for twenty-four hours 
to the exposed pulp. 

Under the full influence of the freezing mixture, 
the circulation in the part is wholly arrested, and the 
sensibility entirely obtunded, so that the operation, 
properly performed, produces no pain. In the ex- 
traction, the gum, so far as congealed, may, if neces- 
sary, be embraced by the forceps and broken away 
without pain. After the operation, cold water or ice 
should be applied to the part, to prevent a too rapid 
re-action, which would be very painful, but which, 
thus graduated, occasions but slight pain, and in some 
cases none at all. 

The aim in all cases should be to produce congela- 
tion to the point of the root; for, without this, 
the extraction will cause pain. And it is far more 
difficult to effect this object where only the root is 
remaining ; for the crown when present, serves as a 
conductor. In the former case, however, a screw or 
iron wire may be introduced into the root, and left 
projecting, to serve as a conductor. But in some 
cases, especially in those of roots, it is improper to 
attempt the employment of congelation at all. The 
practicability of a desirable result will depend much 



LOCAL ANESTHESIA. 



419 



upon the skill and tact of the operator, and the sus- 
ceptibility of the parts. In patients of full habit and 
active circulation, it is very difficult to produce insen- 
sibility by congelation ; and in such cases great pain 
usually attends its application. 

Congelation is now far more easily, and efficiently 
accomplished by the use of ether spray, than by the 
process just described. So easy of application is it, 
and so generally efficient, that it is in almost uni- 
versal use. To Dr. Richardson, of London, is due 
the credit of having brought this process to its pre- 
sent state of perfection. 

So accurately does the accompanying engraving 

Fig. 86. 




(Fig, 86) represent the apparatus used in this process, 
that a minute description is unnecessary. The mode 
of application and operation is apparent at once. 

The instrument consists of the fluid holder — a four 
ounce bottle, graduated — the bellows consisting of a 



420 ANESTHETICS. 

rubber ball, with the proper valves, and the points 
from which proceed the spray, and these all con- 
nected by the proper sized flexible tube. 

It will be observed that there are variously formed 
points, single and double, straight and curved ; these 
are required for the various purposes to which the 
instrument is applied. 

For the extraction of teeth, the double point is 
applicable, throwing a jet upon the gum each side of 
the tooth at the same time. The single points are 
required where an incision or excision is to be made. 

This is a very valuable instrument, and is exten- 
sively used in minor surgical operations, and is espe- 
cially adapted to the dentist's use. Ether is perhaps 
as yet the best agent employed. Rhigolene, a far 
more volatile fluid than ether, has been used to a 
limited extent, but owing to its exceedingly rapid 
evaporation, its action is too violent, and not so easily 
controlled. 



EXTRACTION BY ELECTRO-MAGNETISM. 

The employment of electro-magnetism in the ex- 
traction of teeth was introduced to the profession 
some ten years ago ; and at one time was exten- 
sively used. There is a great diversity of opinion as 
to its efficiency for relieving pain ; for, while some 



EXTRACTION BY ELECTRO-MAGNETISM. 421 

have been disposed to assume that, when properly 
employed, it would, in the majority of cases, miti- 
gate pain, and, in many, obviate it altogether ; 
others, after having thoroughly tested it, as they 
affirm, maintain that it does not produce insensibility 
to any appreciable extent, and consequently does not 
relieve the pain, but that, at most, it only complicates 
the sensations, the pain of the tooth-drawing becom- 
ing involved in the confusion of other feelings, so that 
the patient can hardly decide whether he has been 
definitely hurt or not ! 

In using this agent for the process of extracting 
teeth, the susceptibility of the patient to its influence 
must be carefully regarded. Some persons are so 
peculiarly constituted that an electric current is al- 
most intolerable to them ; while others will receive a 
strong current with pleasurable sensations. To the 
former, the electricity would be as painful as the ex- 
traction of the tooth; but to the latter, when properly 
applied, it mitigates, and in many cases altogether 
obviates, the pain. The reason of this difference in 
its action is not very clearly understood. Several 
theories in regard to it have been advanced, but 
none of them sufficiently plausible to challenge con- 
viction. 

Again, the manner in which, and the condition of 
the parts to which, this agency is applied, are to he 



422 ANESTHETICS. 

closely observed. Where there is acute periostitis, 
an electric current, even though feeble, would produce 
intense pain, and should not be applied ; though, in 
such cases, it has been suggested that an application 
of the charged sponge to the gums will produce insen- 
sibility. 

APPLICATION. 

The method of application is very simple. Any 
ordinary battery, of convenient form, may be em- 
ployed for this purpose. It should be uniform in its 
action, and the vibration as short as possible. The 
common zinc-and-copper battery, with the sulphate- 
of-iron solution, is perhaps the most convenient and 
safe. One pole of the battery — no matter which — is 
attached to the forceps, and the other to a handle of 
size and form convenient for the patient to grasp. -To 
ascertain his susceptibility, the current should always 
first be tested on the patient, by placing the handle 
and the forceps one in each of his hands, and letting 
it on first feebly, and then gradually increasing it till 
he experiences the sensation just beyond the elbows; 
when, finally, it is to be slightly weakened. The 
gum having been separated, the forceps, with its ap- 
pendages, is adjusted to the tooth, the connection 
made by placing the handle in the patient's hand, and 
the tooth at that moment removed. It has been re- 



APPLICATION. 423 

commended by some to place the forceps on the tooth, 
and complete the circuit, as above, with the current 
very feeble, and then gradually increase it to the 
proper force for the operation. In some instances, 
perhaps, this would be the preferable mode. 

Another method of producing insensibility by an 
electric current is, to place two moistened sponges, 
connected with the two poles of the battery, on the 
gum, one on each side of the tooth, keep them there 
a few moments, and then operate. This method ? 
however, has not yet been sufficiently tested to ascer- 
tain its merits. 



INDEX 



Atrophy, 29. 

cause of, 30. 
Amalgam, 90. 
Adhesive foil, 67. 
Actual cautery, 65. 
Arsenious acid, 45, 266. 

application of, 68. 
Alveolar abscess, 97. 

treatment of, 99. 
Attachment of an artificial crown, 314. 
Accidents in the extraction of teeth, 388. 
Anaesthetics, 410. 
Application of electro-magnetism, 422. 

Broaches, 101. 

Bur drill, 96. 

Breaking of the teeth, 402. 

Chloroform, 410. 
Chemical abrasion, 37. 

cause of, 38, 
Comparative liability of the teeth to decay, 63. 
Caries of the teeth, 42. 

causes of, 52. 



426 INDEX. 

Caries, exciting causes of, 56, 

consequences of, 65. 

treatment of, 67. 
Crystal or sponge gold, 88, 174, 198. 
Classification of decayed cavities, 183. 
Creosote or carbolic acid, 241. 
Chloride of zinc, 243. 

Conditions to be observed in extraction of the teeth, 342. 
Cylinder or block filling, 159. 
Cobalt, 271. 

Deposits, 18. 

points of, 20. 
Denuding, 35. 
Drills, 99. 
Drill stocks, 103. 
Drying cavities, 139. 
Destruction of the pulp, 260. 
Dislocation of the inferior maxilla, 406. 
Dental periostitis, 290. 

treatment of, 293. 

Ether, 410. 

Extraction preparatory to the insertion of artificial dentures, 380. 

Exostosis, 32. 

effects of, 34. 

cause of, 34. 
Examination of decays, 135. 
Excavators, 105. 

manufacture of, 109. 
Exposed pulps, 249. 

treatment of, 251. 

destruction of, 260. 
Extraction of teeth, 325, 358. 



INDEX. 427 

Extracting instruments, 334. 
Elevators, 351. 

Extraction by electro-magnetism, 420. 
Extraction of the inferior incisors, 371. 

Filling teeth, 134. 

examination of, 135. 

opening cavities, 136. 

drying cavities, 150. 

removal of decay, 138. 
Forming cavities, 142. 
Forming blocks, 160. 
Finishing fillings, 179. 
Filling by classes and modifications, 185 . 
Filling with foil, 195. • 
Filling with adhesive foil, 196. 

Filling large cavities on the labial surfaces of superior incisors, 231. 
Filling pulp-cavities and canals, 273. 
Forceps, 340. 
Fracture of the alveolus, 400. 



Green tartar, 24. 

its origin, 25. 

treatment of, 26. 
General remarks on filling, 73. 
Gold, 85. 

General remarks on extraction, 325. 
Gum Lancet, 354. 



Hooks, 352. 

Hemorrhage, 389. 

Heavy cutting-instruments, 97. 

Hill's stopping, 94. 



428 INDEX. 

Inferior molars, extraction of, 375. 
Inflamed dentine, 234. 

treatment of, 237. 
Inferior dens sapientise, extraction of, 37' 
Inferior bicuspids, extraction of, 374. 
Introduction, 17. 
Instruments for filling, 97. 
Introducing the filling, 154. 
Introducing the blocks, 163. 
Indications for extraction, 332. 
Inferior cuspids, extraction of, 372. 
Irregularity of the teeth, 27. 

effects of, 28. 

Lead for filling, 81. 
Laceration of the gums, 402. 
Local anaesthesia, 416. 

Materials for filling, 77. 

metallic, 77. 

non-metallic, 93. 
Manufacture of excavators, 109. 
Mode of using the file, 123. 
Metallic pivots, 319. 

Necrosis of the teeth, 39. 

causes of, 41. 
Nitrate of silver, 241. 

Opening cavities, 136. 
Os artificial, 96. 

Platinum, 84. 

Plugging instruments, 111. 



INDEX. 429 

Pathological conditions, 233. 

Potential cautery, 266. 

Preparing the teeth and roots for filling, 281. 

Pivot teeth, 307. 

fitting crowns of, 311. 

attachment of, 314. 
Pellets for filling, 166. 

Removal of the dens sapientise, 368, 379. 
Removal of decay, 138. 
Removal of a wrong tooth 7 403. 

Saliva pump y 190 o 

Screw, 353. 

Silver, 83. 

Separation of the teeth, 127. 

Special cases, 226. 

Superior cuspids, extraction of, 361. 

Superior bicuspids, extraction of, 362, 

Syncope, 408. 

Scranton's drill r 10L 

Tartar, 18. 

origin of, 19. 

points of deposit, 20. 

effects of, 21. 

method of removing, 22. 
Tin, 80. 

The mallet, 171. 
The file, 119. 

use of, 122. 
The palatal portion of the crown broken away, leaving the outer por- 
tion standing — nerve not exposed, 227. 
Treatment of inflamed dentine, 237. 



430 INDEX. 

Tannin or tannic acid, 240. 
Terchloride of gold, 244. 
' The key, 336. 

The method of lancing the gums, 357. 
Treatment of hemorrhage, 391. 

Various preparations of gold, 87. 



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